Att 4 Past Performance Questionairre.pdf

Attachment 4

RFP FA301620R0058

PAST PERFORMANCE QUESTIONNAIRE

The 502nd Contracting squadron Ordering is conducting a source selection for a task order. The offeror has identified you as a reference to validate past performance.

RFP FA301620R0058 is for personal and non-personal PRK Clinical Services at the Department of Defense Military Treatment Facilities (MTF) at Wilford Hall Ambulatory Surgical Center (WHASC) & Joint Warfighter Refractive Surgery Center, Joint Base San Antonio-Lackland. Please complete the following questionnaire to assist our evaluation of the Contractor’s past performance, and return via email no later than 15 June 2020 to Kari Barnett at kari.barnett@us.af.mil and Jorge Canavati at jorge.canavati@us.af.mil.

RESPONDENT INFORMATION:

OFFEROR’S REFERENCE INFORMATION:

CONTRACT INFORMATION:

Contract Number:

Task Order Number:

Type of Contract:

Performance Period: (Base plus any options):

Description of Services:

Contracting Activity/Customer:

Point of Contact (POC):

Title of POC:

Telephone:

Email:

Contractor Name:

Point of Contact (POC):

Telephone Number:

Email:

MARKET SEGMENT

Ancillary Services Dental Services Nursing Services Physician Services

MAGNITUDE

Annual Contract Value:

Total Contract Dollar Value:

COMPLEXITY

Number of FTEs:

Number of Credentialed FTEs:

Number of Privileged FTEs:

Facility Type (i.e., Hospital/Clinic):

Contractor performed on this contract as:

Prime Subcontractor Teaming Partner Joint Venture

Please refer to the following assessment definitions to assess the Contractor’s performance in each of the areas listed in this questionnaire:

(E) 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.

(V) Very 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.

(S) Satisfactory - 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 resolved satisfactorily.

(M) 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.

(U) 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 assess the area.

Overall Fill Rate (CPARS “Quality of Service” Rating Area)

Assess how the Contractor: E V S M U NA Provided qualified HCW’s IAW the terms and conditions of the contract.

Ensured that qualified HCW’s remained filled IAW the terms and conditions of the contract.

Recruited, placed and retained qualified HCW’s with minimal disruption for hard-to-fill (specialty) positions or at remote locations.

If other than “Satisfactory,” explain how the performance exceeds or does not meet contractual requirements:

On-Time Fill Percentage (CPARS “Schedule” Rating Area)

Provide qualified HCW’s on time IAW the Terms and conditions of the contract.

Provided complete, current and accurate qualifying package for each HCW IAW the Terms and

Provided complete, current and accurate credentialing/privileging packages within established time frames IAW the Terms and

Turnover Rate (CPARS “Management” Rating area)

Retained qualified HCWs without frequent turnover and minimal operations disruption IAW the terms of the contract.

Replenishment Rate (CPARS “Management” Rating area)

Planned for and provided replacement candidates during the life of the contract to, include pre-planned/unplanned absences and extended leave of absence to avoid disruption of services and/or work schedule IAW the terms of the contract.

PERFORMANCE SUMMARY Yes No

Would you award this firm another contract:

If you answered “No” provide an explanation:

Was the contract terminated for default or cause:

If you answered “Yes” provide an explanation:

Additional Comments:

Signature: Date:

Print Name:

Title:

Telephone:

Thank you for your participation in providing a detailed and accurate history of past performance for this offeror.