Appendix C - Past Performance Questionnaire (PPQ).docx

APPENDIX C

RELEVANT PAST/PRESENT PERFORMANCE QUESTIONNAIRE

INDIAN HEALTH SERVICE REQUEST FOR PROPOSAL (RFP) 75H70421R00004

WHEN FILLED IN THIS DOCUMENT IS SOURCE SELECTION SENSITIVE INFORMATION IAW FAR 3.104

CONTRACTOR MAY FILL OUT THE SECTIONS 1 & 2 FOR THE CONVENIENCE OF THE EVALUATOR; HOWEVER, EVALUATOR SHALL VERIFY THAT THE INFORMATION PROVIDED BY THE CONTRACTOR IS COMPLETE AND CORRECT.

SECTION 1: CONTRACT IDENTIFICATION

A. Contractor:

B. DUNS of contractor contract was awarded to:

C. Contract number:

D. Contract type:

E. Was this a competitive contract? Yes No

F. Period of performance:

G. Initial contract cost: $

H. Current/final contract cost: $

I. Reasons for differences between initial contract cost and final contract costs:

J. Description of service provided:

SECTION 2: CUSTOMER OR AGENCY IDENTIFICATION

A. Customer or agency name:

SECTION 3: EVALUATOR IDENTIFICATION

A. Evaluator's name:

B. Evaluator's title:

C. Evaluator's phone#:

D. Evaluator’s Email:

E. Number of year’s evaluator worked on subject contract:

SECTION 4: EVALUATION

Please indicate your satisfaction with the contractor’s performance by placing an “X” in the appropriate block using the scale provided to the right of each question. This scale is defined as follows:

CODE PERFORMANCE LEVEL

5 EXCEPTIONAL - The contractor’s performance meets contractual requirements and exceeds many (requirements) to the Government’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

4 GOOD- The contractor’s performance meets contractual requirements and exceeds some (requirements) to the Government’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

3 ACCEPTABLE – The contractor’s performance meets contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the contractor appear or were acceptable.

2 MARGINAL – Performance does not meet some contractual requirements. The contractual performance reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented.

1 UNSATISFACTORY – Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

N NOT APPLICABLE - Unable to provide a score.

The questions shown below should be tailored to the Factors/Subfactors of the instant acquisition.

T1. Overall quality of the support services.

T3. Quality/integrity of data/report preparation and/or presentation efforts

T3. Adequacy/effectiveness of quality control program and adherence to contract quality assurance requirements

P1. Contractor was reasonable and cooperative in dealing with your staff (including the ability to successfully resolve disagreements/disputes)

P2. Timeliness/effectiveness of contract problem resolution without extensive customer guidance

P3. Successfully responded to emergency and/or surge situations

P4. Quality/effectiveness of sub-contracted efforts

P5. Contractor proposed alternative methods/processes that reduced cost, improved maintainability or other factors that benefited the customer

T1. Contractor ability to smoothly transition resources and personnel.

E1. Ability to hire/apply a qualified workforce to this effort.

E2. Ability to retain a qualified workforce on this effort.

E3. Effectiveness of employee compensation towards quality of work.

C2 Ability to meet forecasted costs and perform within contract costs

C3 Ability to alert Government of unforeseen costs before they occur

2. Government Contracts Only: Has/was this contract been partially or completely terminated for default or convenience or are there any pending terminations?

Yes No

Default

Convenience

Pending Terminations

If yes, please explain (e.g., inability to meet cost, performance, or delivery schedules, etc).

SECTION 5: NARRATIVE SUMMARY

Would you have any reservations about soliciting this contractor in the future or having them perform one of your critical and demanding programs?

Overall, was the customer satisfied with the contractor’s services? Did they exceed the government’s expectation?

Evaluator’s Signature Date

Please return this completed questionnaire to:

Email Address: paul.premoe@ihs.gov

Thank you for your prompt response and assistance!