Attachment 11 - Relevant Experience Template .pdf

1 Source Selection Information - See FAR 2.101 and 3.104

RELEVANT EXPERIENCE TEMPLATE

This template may be modified to account for information that exceeds the amount of space provided.

However, the format must remain as provided and each relevant experience citation (contract / task order) may not exceed two pages. Use a separate template for each of the three contracts / task orders.

1. FEDERAL AGENCY / PROGRAM

NAME:

2. CONTRACT / TASK ORDER NUMBER:

3. ROLE

(PRIME OR SUBCONTRACTOR):

4. GEOGRAPHIC LOCATION(S) OF PERFORMED CONTRACT WORK:

5. DATE OF AWARD: 6. PERIOD OF PERFORMANCE:

7. CUSTOMER POINTS OF CONTACT (POC)

(PROVIDE NAMES, ADDRESSES, TELEPHONE NUMBERS, AND EMAIL ADDRESS FOR EACH POC BELOW)

A. PROGRAM MANAGER:

B. CONTRACTING OFFICER:

C. COR / TASK MONITOR:

8. CONTRACT / TASK ORDER INFORMATION

A. CONTRACT TYPE

(E.G., T&M, FFP):

B. IF THE CONTRACT / TASK ORDER

HAS BEEN COMPLETED, PROVIDE THE

PROGRAM PRICE / COST:

(1) DOLLAR AMOUNT AT AWARD:

(2) DOLLAR AMOUNT AT

COMPLETION:

C. IF THE CONTRACT HAS NOT BEEN

COMPLETED:

(1) CURRENT PRICE / COST:

(2) CURRENT ESTIMATE TO

COMPLETE:

2 Source Selection Information - See FAR 2.101 and 3.104

9. PROJECT SCOPE AND COMPLEXITY

(DESCRIBE HOW THIS PROJECT IS SIMILAR IN SCOPE AND COMPLEXITY AND RELEVANT TO THE TASKS DELINEATED IN THE

RFP TO SPECIFICALLY INCLUDE SCOPE OF WORK AND PRACTICE STATED IN THE STATEMENT OF

WORK)

10. QUALITY CONTROL ACTIVITIES

(PROVIDE ANY QUALITY CONTROL ACTIVITIES THAT WERE SUCCESSFULLY PERFORMED AS THEY RELATE TO MEDICAL EXAMINATIONS AND

QUALITY OF CARE PROVIDED)

11. MANAGEMENT OF CREDENTIALED PROVIDERS AND PERSONNEL

(DESCRIBE HOW THE CONTRACTOR WAS ABLE TO SUCCESSFULLY MANAGE MULTIPLE LOCATIONS OF PROVIDERS WITH MINIMAL

DISRUPTION)

12. ISSUES ENCOUNTERED

(DESCRIBE ANY ADVERSE PERFORMANCE ISSUES ENCOUNTERED DURING THE PERFORMANCE PERIOD AND THE REMEDIAL ACTIONS TAKEN

TO CORRECT THE ISSUES)

13. ADDITIONAL COMMENTS

(PROVIDE ANY ADDITIONAL COMMENTS / INFORMATION CONTRACT DEEMS RELEVANT TO PAST PERFORMANCE