AHRQ-11-1006-Attachment 4-Past Performance Questoinaire.pdf

ATTACHMENT 4

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-11-10006, entitled “Health Care Innovations Exchange II.” 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 Erin Mills, 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 February 2, 2011. If you have any questions, please contact Ms. Nicola L. Carmichael at (301) 427-1705.

Erin Mills Agency for Healthcare Research and Quality Division of Contracts Management 540 Gaither Road Rockville, Maryland 20850

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: ________________________________

7. Type of Contract/Grant: (Check all that apply) ( )FP ( )FPI ( )FP-EPA ( ) Award Fee ( ) CPFF-Completion ( ) CPFF-Term ( ) CPIF ( ) CPAF ( ) IO/IQ ( ) BOA ( ) Requirements ( ) Labor-Hour ( )T&M ( ) SBSA ( )8(a) ( )SBIR ( ) Sealed Bid( )Negotiated( )Competitive ( )Non-Competitive

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

Comments 0

Timeliness of Performance

Comments 0

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.

Quality Cost Control Timeliness of

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/cooperati ve -Flexible -Pro-active -Effective small/small disadvantaged business sub-contracting program

0-unsatisfactory Nonconformances are 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/admi nistrative issues is not effective

1-Poor Overall compliance 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/admi nistrative issues is marginally effective

2-Fair Overall compliance 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, technical/service/admi nistrative issues is somewhat

3-Good Overall compliance does 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, technical/service/admi nistrative issues is usually

4-Excellent There are no quality problems

There are no cost management issues

There are no delays

Response to inquiries, technical/service/admi nistrative 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.”