83979 Att H - Reference Check Form.docx

Attachment HState of Indiana Contact:

Christina Garcia, Strategic Sourcing Analyst CGarcia@idoa.IN.gov Indiana Department of Administration

Reference Check Form

RFP 25-83979

Therapy Services

Reference Check Form Due Date:

September 29, 2025

INSTRUCTIONS: You have been asked by the vendor listed below to provide a reference as they are responding the current solicitation with the state of Indiana. This is a standard form created by the State of Indiana and your input is very much appreciated. During this competitive process, a representative from the State of Indiana, may contact you directly for more detail. If you have any questions, please contact the State of Indiana contact listed in the box in the top left side of the form.

Please provide the information requested below and submit this reference check form to:

idoareferences@idoa.in.gov:

The subject line of the email submissions must clearly state the following:

RFP 25-83979 Reference – [INSERT COMPANY NAME]

VENDOR NAME

REFERENCE CONTACT INFORMATION

Reference Company Name

Contact Name

Contact Title

Company Mailing Address

Company City, State, Zip

Company Website Address

Contact Telephone Number

Contact Fax Number

Contact Email

Industry of Company

QUESTIONS: Please provide a response to each of the questions listed below regarding the vendor listed above.

1. If you decline to provide a reference, please indicate that below and provide any comments you would be willing to share regarding the reason.

2. How long did you/have you and/or members of your team worked with the vendor? Please provide the specific dates of service.

3. With what type of internal and external stakeholders did the vendor have to communicate with?

4. Has the vendor been cited for any financial audit issues? If you are able to, please describe the issue briefly, and any corrective actions required. Did the vendor ultimately address the issue(s) in a satisfactory manner?

5. Has the vendor been subject to any requests for corrective action to cure performance issues? If you are able to, please describe the issue briefly, and any corrective actions required. Did the vendor ultimately address the issue(s) in a satisfactory manner?

6. Would you rate your experience with the quality of services/work provided by vendor as poor, satisfactory, above average or superior? Please elaborate on why you are giving the vendor this rating.

7. Would you rate the vendor's knowledge of your business as poor, satisfactory, above average or superior? Please elaborate on why you are giving the vendor this rating.

8. Would you rate the overall quality of the vendor’s staff as poor, satisfactory, above average or superior? Please elaborate on why you are giving the vendor this rating.

9. Would you describe the quality of the vendor’s engagement and communication with stakeholders (internal and external) throughout the project as poor, satisfactory, above average or superior? Please elaborate on why you are giving the vendor this rating.

10. Would you rate the vendor’s ability to provide appropriate staff and resources for the project, as needed, at all times as poor, satisfactory, above average or superior? Please elaborate on why you are giving the vendor this rating.

11. Would you rate the vendor's performance regarding cost and/or schedule overruns on the project as poor, satisfactory, above average or superior? Please elaborate on why you are giving the vendor this rating.

12. Are there any other topics you believe Indiana should consider during its reference evaluation or comments you would like to share?

13. Would your overall rating of the vendor be poor, satisfactory, above average or superior?