A5 - 75H70925Q00005 Past Performance Survey.docx
DOCX document 45 KB Posted
- Attached to
- BFSU Locum Provider Staffing Services
- Solicitation number
- 75H70925Q00005
About this file
The document is a Past Performance Survey template for a federal contract opportunity (Solicitation Number 75H70925Q00005) for Locum Provider Staffing Services with the Billings Area Indian Health Service. The solicitation is a 100% Buy Indian Small Business Set-Aside specifically targeting Indian Small Business Economic Enterprises (ISBEEs) under NAICS code 561320 (Temporary Help Services) with a small business size standard of $34 million. The procurement is a commercial items Request for Quotation (RFQ) for non-personal healthcare staffing services, issued by the Department of Health and Human Services Indian Health Service. The survey template requires detailed information about past contract performance, including contract details, points of contact, work locations, contract status, contract descriptions, and optional attachments such as CPARS evaluations to help assess a contractor's past performance capabilities.
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Other files
| File | Type | Posted |
|---|---|---|
| Sol_75H70925Q00005_Amd_0002.pdf | ||
| 75H70925Q00005 Q and A.pdf | ||
| Sol_75H70925Q00005_Amd_0001.pdf | ||
| A1 - PWS Locum Provider Services AMD 01.pdf | ||
| Sol_75H70925Q00005.pdf | ||
| A4 - IEE Representation.pdf | ||
| A2- QASP Locum Provider Services.docx | DOCX document | |
| A3 - Price Schedule.xlsx | XLSX spreadsheet | |
| A1 - PWS Locum Provider Services.pdf |
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Text version
75H70925Q00005 Attachment #A5 – Past Performance Survey
1. Complete Name of Reference (Government agency, commercial firm, or other organization)
2. Complete Address of Reference
| 3. Contract Number or other control number |
| 4. Date of contract |
| 5. Date work was begun |
| 6. Date work was completed |
7. Contract type, initial contract price, estimated cost and fee, or target cost and profit or fee
8. Final amount invoiced or amount invoiced to date
9a. Reference/Technical point of contact (name, title, address, telephone
no. and email address) 9b. Reference/Contracting point of contact (name, title, address, telephone no. and email address)
10. Location of work (country, state or province, county, city)
| 11. Current status of contract (choose one): | [ ] Work completed, claims negotiations pending or underway | |
| [ ] Work continuing, on schedule | [ ] Work completed, litigation pending or underway | |
| [ ] Work continuing, behind schedule | [ ] Terminated for Convenience [ ] Work completed, no further action pending or underway | [ ] Terminated for Default |
| [ ] Work completed, routine administrative action pending or underway | [ ] Other (explain) |
12. Provide a summary description of contract work. Describe the nature and scope of work, its relevancy to this solicitation, and a description of any problems encountered and the contractor's corrective actions. Attach the explanation to this form.
13. Describe the extent to which the reference contractor (and its subcontractors) on the cited solicitation contributed to the effort described in Block 12.
14. Please attach CPARS evaluations for all portions of the past three (3) years on the contract, if available. If evaluations other than CPARS were completed, please attach them. Please provide reference(s) the Government may contact in order to respond to Past Performance questions about the reference contractor.
TO-RFP: 75H709-BAIHS23Q-004
Attachment #3 – Past Performance Survey
1. Complete Name of Reference / Facility (Government agency, commercial firm, or other organization)
2. Complete Address of Reference / Facility
| 3. Contract Number and task order or other control number |
| 4. Date of contract award |
| 5. Period of Performance Start Date |
| 6. Period of Performance End Date |
7. Contract type, initial total contract price/task order price
8. Final amount invoiced or amount invoiced to date
9a. Reference/Technical point of contact (name, title, address, telephone
no. and email address) 9b. Reference/Contracting Office point of contact (name, title, address, telephone no. and email address)
10. Location of work (country, state or province, county, city)
| 11. Current status of contract (choose one): | [ ] Work completed, claims negotiations pending or underway | |
| [ ] Work continuing, on schedule | [ ] Work completed, litigation pending or underway | |
| [ ] Work continuing, behind schedule | [ ] Terminated for Convenience [ ] Work completed, no further action pending or underway | [ ] Terminated for Default |
| [ ] Work completed, routine administrative action pending or underway | [ ] Other (explain) |
12. Provide a summary description of contract work. Describe the nature and scope of work, its relevancy to this solicitation, and a description of any problems encountered and the contractor's corrective actions. Attach the explanation to this form.
13. Describe the extent to which the reference contractor (and its subcontractors) on the cited solicitation contributed to the effort described in Block 12.
14. Please attach CPARS evaluations for all portions of the past three (3) years on the contract, if available. If evaluations other than CPARS were completed, please attach them. Please provide reference(s) the Government may contact in order to respond to Past Performance questions about the reference contractor.
1. Complete Name of Reference / Facility (Government agency, commercial firm, or other organization)
2. Complete Address of Reference / Facility
| 3. Contract Number and task order or other control number |
| 4. Date of contract award |
| 5. Period of Performance Start Date |
| 6. Period of Performance End Date |
7. Contract type, initial total contract price/ task order price
8. Final amount invoiced or amount invoiced to date
9a. Reference/Technical point of contact (name, title, address, telephone
no. and email address) 9b. Reference/Contracting Office point of contact (name, title, address, telephone no. and email address)
10. Location of work (country, state or province, county, city)
| 11. Current status of contract (choose one): | [ ] Work completed, claims negotiations pending or underway | |
| [ ] Work continuing, on schedule | [ ] Work completed, litigation pending or underway | |
| [ ] Work continuing, behind schedule | [ ] Terminated for Convenience [ ] Work completed, no further action pending or underway | [ ] Terminated for Default |
| [ ] Work completed, routine administrative action pending or underway | [ ] Other (explain) |
12. Provide a summary description of contract work. Describe the nature and scope of work, its relevancy to this solicitation, and a description of any problems encountered and the contractor's corrective actions. Attach the explanation to this form.
13. Describe the extent to which the reference contractor (and its subcontractors) on the cited solicitation contributed to the effort described in Block 12.
14. Please attach CPARS evaluations for all portions of the past three (3) years on the contract, if available. If evaluations other than CPARS were completed, please attach them. Please provide reference(s) the Government may contact in order to respond to Past Performance questions about the reference contractor.
1. Complete Name of Reference / Facility (Government agency, commercial firm, or other organization)
2. Complete Address of Reference / Facility
| 3. Contract Number and task order or other control number |
| 4. Date of contract award |
| 5. Period of Performance Start Date |
| 6. Period of Performance End Date |
7. Contract type, initial total contract price/ task order price
8. Final amount invoiced or amount invoiced to date
9a. Reference/Technical point of contact (name, title, address, telephone
no. and email address) 9b. Reference/Contracting Office point of contact (name, title, address, telephone no. and email address)
10. Location of work (country, state or province, county, city)
| 11. Current status of contract (choose one): | [ ] Work completed, claims negotiations pending or underway | |
| [ ] Work continuing, on schedule | [ ] Work completed, litigation pending or underway | |
| [ ] Work continuing, behind schedule | [ ] Terminated for Convenience [ ] Work completed, no further action pending or underway | [ ] Terminated for Default |
| [ ] Work completed, routine administrative action pending or underway | [ ] Other (explain) |
12. Provide a summary description of contract work. Describe the nature and scope of work, its relevancy to this solicitation, and a description of any problems encountered and the contractor's corrective actions. Attach the explanation to this form.
13. Describe the extent to which the reference contractor (and its subcontractors) on the cited solicitation contributed to the effort described in Block 12.
14. Please attach CPARS evaluations for all portions of the past three (3) years on the contract, if available. If evaluations other than CPARS were completed, please attach them. Please provide reference(s) the Government may contact in order to respond to Past Performance questions about the reference contractor.
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