Past Performance Questionnaire.doc

75H71123R00001

PROCUREMENT SENSITIVE WHEN COMPLETED

FOR OFFICIAL USE ONLY

SOLICITATION 75H71123R00001

PAST PERFORMANCE QUESTIONNAIRE

To: _______________________________________________________________________

Organization:_____________________________________________________________

Fax No.: _________________________ E-mail Address:_________________________

Date: __________________________ Number of Pages (including this sheet): 5 in total Client Authorization Letter

Dear (Commercial Client/Customer)

We are currently responding to the Indian Health Services solicitation 75H711Q23R00001 for the LAWTON Indian Hospital Emergency Department physician services.

The Government is placing increased emphasis on past performance in order to obtain best value in source selections. They are requesting that clients of companies who submit proposals in response to their solicitation for the program/effort identified above be identified and that their participation in the validation process be requested. Therefore, in the event you are contacted for information on work we have performed on (list program); you are hereby authorized to respond to those inquiries.

We have identified Mr./Ms. (Name) of your organization as the point of contact based on their knowledge concerning our work. Your cooperation is appreciated. Any questions may be directed to (Name, title, phone number and fax number for the POC) Your name was provided as a past performance point of contract for the following:

Contractor Name:_________________________________________________________

Contract Number: _______________________________ Date(s)____________________

Project Title: ___________________________________________________________

Contractor Role / Responsibility (circle one): Prime Contractor Sub-Contractor

In regard to the above contractor’s performance on the referenced contract, please complete the attached Past Performance Questionnaire and return as follows:

Send to:

E-mail Address:

For questions, please contact me at telephone Please provide your response no later than Thank you!

Please complete and/or verify the following reference check information:

1. Name of Contractor: ____________________________________________________

2. Type of contract/agreement for pricing; e.g., firm fixed-price, fixed rate per hour (labor-hour, T&M), cost-reimbursable:

3. Contract Number: _________________________________

4. Total Contract Amount: $____________________________

5. Date of Contract Award: ____________________________

6. Contract Period of Performance: Start _________________ Complete_____________

A. Please complete and/or verify the following responder information:

Name of Responding Point of Contact: _____________________________________________________

Agency/Organization: _________________________________________________________________

Mailing Address:

Telephone Number:

E-mail Address:

1.

How would you rate the contractor's overall compliance with contract requirements?

2.

How would you rate the timeliness of the Contractor - adhering to the required schedule?

3.

Has this contract been partially or completely terminated for default, or is a termination pending?

( ) Yes / If yes, please explain and indicate the status.

( ) No/Acceptable

4.

Has it ever been necessary to send this Contractor a Notice to Cure letter?

( ) Yes If yes, please explain and indicate the status.

( ) No/Acceptable

5.

How would you rate the performance of the contractor's key personnel?

6.

Would you recommend awarding similar contracts or using the offeror again for future work?

( ) Yes

( ) No

7.

Did you experience any integrity problems with this Contractor?

( ) Yes If yes, please explain.

( ) No/Acceptable

8.

Please provide any other comments you may have.