Attachment 10 Past Performance Questionnaire.docx
DOCX document 16 KB Posted
- Solicitation number
- 75H70124R00012
About this file
This document contains a past performance questionnaire template for contractors to provide to their clients for feedback on previous federal contract work. The questionnaire requests information on a contractor's performance on quality, schedule, cost control, management, and regulatory compliance for a prime or subcontract with the Indian Health Service, which manages healthcare for Native Americans. Ratings are defined on a scale from exceptional to unsatisfactory.
The related federal contract opportunity is a solicitation from the Department of Health and Human Services Indian Health Service to renovate and expand the emergency department at the Gallup Indian Medical Center. Details include the solicitation number, project name, opportunity type as a solicitation, and issuing agency.
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Text version
PAST PERFORMANCE QUESTIONNAIRE
Instructions to client:
The contractor is proposing for a construction contract with Indian Health Service https://www.ihs.gov/ You are requested to complete this form, sign, and return it to the contractor so it may be submitted with their proposal.
PART I CONTRACT INFORMATION (Contractor to complete)
Contractor Name:
Project Title
Award Value
Period of Performance
| Prime Contractor or Subcontractor |
| ☐ Prime ☐ Subcontractor |
Agency or Entity Name and Address
PART II PERFORMANCE INFORMATION (Client to complete)
Name / Title
Phone #
Email Address
Contract Type
Signature
Instructions: Please select the adjective rating that best reflects your evaluation of the contractor’s performance. See Part III for rating guidance.
| Category |
| Exceptional |
| Good |
| Satisfactory |
| Marginal |
| Unsatisfactory |
| N/A |
Quality
Schedule
Cost Control
Management
Small Business
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Regulatory Compliance | |||||
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Comments (expand as needed) |
PART III RATING GUIDANCE
| RATING |
| DEFINITION |
| NOTE |
| (E) Exceptional |
| Performance meets contractual requirements and exceeds many to the Government/Owner’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor was highly effective. |
| An Exceptional rating is appropriate when the Contractor successfully performed multiple significant events that were of benefit to the Government/Owner. A singular benefit, however, could be of such magnitude that it alone constitutes an Exceptional rating. Also, there should have been NO significant weaknesses identified. |
| (G) Good |
| Performance meets contractual requirements and exceeds some to the Government’s/Owner’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective. |
| A Good rating is appropriate when the Contractor successfully performed a significant event that was a benefit to the Government/Owner. There should have been no significant weaknesses identified. |
| (S) Satisfactory |
| Performance meets minimum contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory. |
| A Satisfactory rating is appropriate when there were only minor problems, or major problems that the contractor recovered from without impact to the contract. There should have been NO significant weaknesses identified. Per DOD policy, a fundamental principle of assigning ratings is that contractors will not be assessed a rating lower than Satisfactory solely for not performing beyond the requirements of the contract. |
| (M) Marginal |
| Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor's proposed actions appear only marginally effective or were not fully implemented. |
| A Marginal is appropriate when a significant event occurred that the contractor had trouble overcoming which impacted the Government/Owner. |
| (U) Unsatisfactory |
| Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains serious problem(s) for which the contractor's corrective actions appear or were ineffective. |
| An Unsatisfactory rating is appropriate when multiple significant events occurred that the contractor had trouble overcoming and which impacted the Government/Owner. A singular problem, however, could be of such serious magnitude that it alone constitutes an unsatisfactory rating. |
| (N) Not Applicable |
| No information or did not apply to your contract |
| Rating will be neither positive nor negative. |
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