A3 - 75H70926Q00001 Past Performance Survey.docx
DOCX document 47 KB Posted
- Solicitation number
- 75H70926Q00001
About this file
This document is a Past Performance Survey template for the Billings Area Wide Tele Behavioral Health Services solicitation (75H70926Q00001). The survey is designed to collect comprehensive reference information about a contractor's previous work, including contract details such as contract number, dates of performance, contract type, invoiced amounts, and points of contact. The form requires detailed information about the contract's status, a summary description of work performed, and requests attachments like CPARS evaluations from the past three years.
The related federal contract opportunity is a 100% Buy Indian Small Business Set-Aside for Tele Behavioral Health & Tele Emergency Behavioral Health Services issued by the Indian Health Service (HHS). The solicitation is specifically targeted at eligible Indian Small Business Economic Enterprises (ISBEEs) for commercial healthcare services, with a NAICS code of 621112 (Offices of Physicians, Mental Health Specialists) and a small business size standard of $13.5 million. Offerors must certify their eligibility under the Buy Indian Act, and only offers from qualifying firms will be considered for award.
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Other files
| File | Type | Posted |
|---|---|---|
| Sol_75H70926Q00001.pdf | ||
| A2 - Price Schedule.xlsx | XLSX spreadsheet | |
| A1 - PWS Telebehavioral and ER Health Services.pdf | ||
| A5 - IEE Representation.pdf | ||
| A4 - Patient Volume.pdf |
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Text version
75H70926Q00001 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.
75H70925Q00003 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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