Attach 3_Past Performance Questionnaire_OR_SPD Techs_22-R-0016_8 July 2022.docx

Attachment 3

PAST PERFORMANCE QUESTIONNAIRE

The Regional Health Contracting Office – Central (RHCO-C) is conducting a competitive acquisition for Personal services for 73 Full Time Equivalent (FTEs), compromised of 31 FTEs Surgical Technologists (Operating Room-OR), two (2) FTEs Cardiothoracic Surgical Technologists (CT Surg Techs), and 40 FTEs Central Sterile Supply Technicians (Sterilization/Processing/Distribution-SPD) at Brooke Army Medical Center (BAMC), Level I Trauma Center, JBSA, Fort Sam Houston, Texas. The offeror has identified you as a reference to validate past performance.

Please complete the following questionnaire to assist our evaluation of the contractor’s past performance, and return to rosalba.martinez1.civ@mail.mil and robin.m.castro.civ@mail.mil by 21 July 2022, 2:00PM CT

Name of Contractor being evaluated:

Note: Clearly identify and provide the name of the Prime Contractor and Subcontractor. Specify Prime Contractor/Subcontractor if known.

Contract/Order Number: __________________________________________________________________

1. Type of service being provided?

2. Where is the location of this service?

3. What is the contract amount?

4. How many Full Time Equivalents (FTE) are on the contract?

5. Have there been any unsatisfactory performance resulting in additional contractual or administrative costs?

Yes |_| No |_| If “Yes,” explain:

The last two questions will discuss quality of service & customer relations. Please refer to the following:

Rating System:

1. Acceptable – Performance meets contractual requirements. Corrective actions taken by the contractor were effective. The offeror has successfully performed the required effort.

1. Unacceptable – Performance does not meet most contractual requirements. Serious problems with contractor performance were experienced for which the corrective actions were ineffective. The offeror has not successfully performed the required effort.

PAST PERFORMANCE QUESTIONNAIRE, Continued

6. Quality of Service – Please rate overall compliance with the contract Performance Work Statement.

(1) Acceptable |_| (2) Unacceptable |_|

Comments:

7. Business/Customer Relations – Please rate overall effective management; successfully managed services; reasonable/cooperative behavior; flexibility; business-like concern for customer’s interest.

(1) Acceptable |_| (2) Unacceptable |_|

Comments:

Signature: Date:

Print Name: Company:

Title: Telephone:

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