A3 - 75H70925Q00011 Past Performance Survey.docx
DOCX document 45 KB Posted
- Solicitation number
- 75H70925Q00011
About this file
This is a Past Performance Survey template form that contractors must complete as part of their proposal submission for solicitation 75H70925Q00011, which seeks preventative maintenance services for radiology equipment at the Crow Service Unit under the Billings Area Indian Health Service. The document contains multiple identical survey forms requiring contractors to provide detailed information about previous contracts, including reference organization details, contract numbers, performance periods, contract types and values, final invoiced amounts, and both technical and contracting points of contact.
Each survey form requests comprehensive information about the contractor's past work performance, including contract status indicators (completed, continuing on schedule, behind schedule, terminated, etc.), detailed descriptions of work scope and relevance to the current solicitation, explanations of any problems encountered and corrective actions taken, and the extent of contractor and subcontractor contributions to the referenced work. The forms also require attachment of CPARS (Contractor Performance Assessment Reporting System) evaluations from the past three years or other performance evaluations if available. This past performance documentation will be used by the government to evaluate contractors' ability to successfully perform the radiology equipment maintenance services under this 100% Small Business Set-Aside procurement with NAICS code 811210 and a $34 million size standard.
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Other files
| File | Type | Posted |
|---|---|---|
| 75H70925Q00011 QA.pdf | ||
| Sol_75H70925Q00011.pdf | ||
| A1 - SOW.pdf | ||
| A2 - Price Schedule.xlsx | XLSX spreadsheet |
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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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