Attachment 2 - Past Performance Questionnaire.docx
DOCX document 32 KB Posted
- Attached to
- Ground Ambulance Services at Ft. Polk, LA
- Solicitation number
- W81K00-26-R-A051
- Issued by
-
Department of the Army Medical Command
About this file
This is a Past Performance Questionnaire attachment for the Ground Ambulance Services solicitation at Fort Polk, LA. The questionnaire is a template document designed to collect information from offerors regarding their prior experience and performance history relevant to the ground ambulance services contract. As a template, this attachment does not specify required products or services but rather serves as the evaluation instrument through which offerors will demonstrate their qualifications and past performance on similar contracts. Offerors are expected to complete this questionnaire as part of their proposal submission to the contracting officer at the Department of the Army Medical Command, with proposals due by October 21, 2026.
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Text version
PAST PERFORMANCE QUESTIONNAIRE
The Medical Acquisition Support Office – Omega (MASO-O) is conducting a competitive acquisition for Ground Ambulance Services at Fort Polk, LA. 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 via email no later than 21 October 2026, 8:00 AM/CDT to marc.a.flores3.civ@health.mil and salameya.paulouskaya2.civ@health.mil.
RESPONDENT INFORMATION:
Contracting Activity/Customer:
Point of Contact (POC):
Title of POC:
Telephone:
Email:
OFFEROR’S REFERENCE INFORMATION:
Contractor Name:
Point of Contact (POC):
Telephone Number:
Email:
CONTRACT INFORMATION:
Contract Number:
Task Order Number:
Type of Contract:
Performance Period: (Base plus any options):
Total Contract Dollar Value:
Description of Services:
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.
Quality
| Assess how the Contractor: |
| E |
| V |
| S |
| M |
| U |
| NA |
Conformed to contract or order requirements, specifications and standards of good workmanship (e.g., commonly accepted technical, professional, environmental, or safety and health standards).
If other than “Satisfactory,” explain how the performance exceeds or does not meet contractual requirements:
Schedule
| Assess how the Contractor: |
| E |
| V |
| S |
| M |
| U |
| NA |
Was timely against the completion of the contract, task orders, milestones, delivery schedules, and administrative requirements (e.g., efforts that contribute to or affect the schedule variance).
If other than “Satisfactory,” explain how the performance exceeds or does not meet contractual requirements:
Management
| Assess how the Contractor: |
| E |
| V |
| S |
| M |
| U |
| NA |
Completed integration and coordination of all activity needed to execute the contract or order, specifically the timeliness, completeness and quality of problem identification, corrective action plans, proposal submittals, the Contractor's history of reasonable and cooperative behavior (to include timely identification of issues in controversy), customer satisfaction, timely award and management of subcontracts
If other than “Satisfactory,” explain how the performance exceeds or does not meet contractual requirements:
Regulatory Compliance
| Assess how the Contractor: |
| E |
| V |
| S |
| M |
| U |
| NA |
Complied with all terms and conditions in the contract/order relating to applicable regulations and codes
If other than “Satisfactory,” explain how the performance exceeds or does not meet contractual requirements:
| 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.
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