Attachment 2_Past Performance Questionnaire_12 November 2020.docx

ATTACHMENT 2

W81K00-21-R-3005 12 November 2020

PAST PERFORMANCE QUESTIONNAIRE

The Regional Health Contracting Office – Central (RHCO-C) is conducting a competitive acquisition for Emergency Medicine Physicians in support of the Evans Army Community Hospital (EACH), Emergency Department, Fort Carson, Colorado. 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 vickie.v.drumming.civ@mail.mil and robin.m.castro.civ@mail.mil by 15 December 2020, 2:00PM CT (San Antonio, Texas). Note: Clearly identify and provide the name of the Prime Contractor and Subcontractor. Specify Prime Contractor/Subcontractor.

Name of Contractor being evaluated:

Contract/Order Number: __________________________________________________________________

1. How long has your company had a contract with this contractor?

2. Type of service being provided?

3. Where is the location of this service?

4. What is the contract amount?

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

6. Have there been late deliveries or other 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. Excellent – Overall performance exceeds contractual requirements and gives extra benefits to the customer. Problems, if any, were promptly corrected without negative impact to the customer.

1. Satisfactory – Performance meets contractual requirements. The contractual performance contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory

1. Marginal - Performance does not meet some contractual requirements. The contractor’s proposed actions to correct any problems appear only marginally effective or were not fully implemented.

1. Unsatisfactory – Performance does not meet most contractual requirements. The contractual performance contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

IMPORTANT NOTE: NARRATIVES MUST BE PROVIDED FOR ANY RATING OTHER THAN SATISFACTORY AND MUST SUPPORT THE RATING GIVEN.

PAST PERFORMANCE QUESTIONNAIRE, Continued

7. Quality of Service – Please rate overall compliance with contract statement of work requirement.

(1) Excellent |_| (2) Satisfactory |_| (3) Marginal |_| (4) Unsatisfactory |_|

If other than “Satisfactory,” a narrative must be provided to explain how the overall performance exceeds or does not meet contractual requirements:

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

(1) Excellent |_| (2) Satisfactory |_| (3) Marginal |_| (4) Unsatisfactory |_|

If other than “Satisfactory,” a narrative must be provided to explain how the overall performance exceeds or does not meet contractual requirements:

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.