Past Performance Questoinaire.docx

ATTACHMENT 1

PAST PERFORMANCE QUESTIONNAIRE

PART ONE: INSTRUCTIONS

The offeror listed below has submitted a proposal in response to the Agency for Healthcare Research and Quality (AHRQ) Solicitation No. AHRQ-11-10001, entitled “Coordinating and Technical Assistance Center for the Pediatric Quality Measures Program.” Past performance is an important part of the evaluation criteria for this acquisition, so input from previous customers of the offeror is important. This office would greatly appreciate you taking the time to complete this form. This information is to be provided to Nicola L. Carmichael, the AHRQ Contract Specialist and is NOT to be disclosed to the offeror either verbally or in writing. Please provide an honest assessment and return to AHRQ to the address shown below, no later than December 10, 2010. If you have any questions, please contact Ms. Nicola L. Carmichael at (301) 427-1705.

FAX: (301) 427-1740

NAME OF OFFEROR:_____________________________________

ADDRESS:_____________________________________________

Contractor Performance Form

1. Name of Contractor:______________________________

2. Address:_________________________________________

3. Contract/Grant Number: _______________________________________

4. Contract/Grant Value (Base Plus Options): ________________________

5. Contract/Grant Award Date: ____________________________________

6. Contract/Grant Completion Date: ________________________________

8. Description of Requirement:

CONTRACTOR’S PERFORMANCE RATING

Ratings: Summarize contractor performance and circle in the column on the right the number which corresponds to the performance rating for each rating category. Please see reverse page for explanation of rating scale.

Quality of Product or Service

Comments

Cost Control

Timeliness of Performance

Business Relations

Comments

Customer Satisfaction - Is/was the Contractor committed to customer satisfaction? Yes No ;

Would you use this Contractor again? Yes No

Reason:

NAME OF EVALUATOR: ________________________________________

TITLE OF EVALUATOR: ________________________________________

SIGNATURE OF EVALUATOR:___________________________________

DATE:_____________________

MAILING ADDRESS:

PHONE #:__________________________________

Rating Guidelines: Summarize contractor performance in each of the rating areas. Assign each area a rating 0(Unsatisfactory), 1(Poor), 2(Fair), 3(Good), 4(Excellent) 5(Outstanding). Use the following instructions as guidance in making these evaluations.

Performance Business Relation

-Compliance with contract requirements -Accuracy of reports -Technical excellence -Within budget(over/ under target costs) -Current, accurate, and complete billings -Relationship of negotiated costs to actual -Cost efficiencies -Change orders issue -Met interim milestones -Reliable -Responsive to technical direction -Completed on time, including wrap-up and contract adm -No liquidated damages assessed -Effective management -Businesslike correspondence -Responsive to contract requirements -Prompt notification of problems -Reasonable/cooperative -Flexible -Pro-active -Effective small/small disadvantaged business sub-contracting program

jeopardizing the achievement of contract requirements, despite use of Agency resources Ability to manage cost issues is jeopardizing performance of contract requirements, despite use of Agency resources Delays are jeopardizing the achievement of contract requirements, despite use of Agency’s resources Response to inquiries, technical/service/administrative issues is not effective

requires major Agency resources to ensure achievement of contract requirements Ability to manage cost issues requires major Agency resources to ensure achievement of contract requirements Delays require major Agency resources to ensure achievement of contract requirements Response to inquiries, technical/service/administrative issues is marginally effective

requires minor Agency resources to ensure achievement of contract requirements Ability to manage cost issues requires minor Agency resources to ensure achievement of contract requirements Delays require minor Agency resources to ensure achievement of contract requirements Response to inquiries, issues is somewhat effective

not impact achievement of contract requirements

Management of cost issues does not impact achievement of contract requirements Delays do not impact achievement of contract requirements

Response to inquiries, issues is usually effective

problems

There are no cost management issues

issues is effective

5-Outstanding. The Contractor has demonstrated an outstanding performance level that justifies adding a point to the score. It is expected that this rating will be used in those rare circumstances where Contractor performance clearly exceeds the performance levels described as “Excellent.”