Attachment 2 - Past Performance Questionnaire.docx

PAST PERFORMANCE QUESTIONNAIRE

The Defense Health Agency Contracting Activity, Healthcare Contracting Division – West is conducting a solicitation among 8(a) small businesses set-aside. The offeror has identified you as a reference to validate past performance.

Solicitation Number, HT941026R2001 is for nonpersonal services of Integrated Referral Management and Appointing Center (IRMAC) services via centralized Patient Appointing Services (PAS), Referral Management Services (RMS), and Clear and Legible Report accountability Services (CLR) for Defense Health Network Indo-Pacific Military Treatment Facilities (MTF) in Hawaii and the Pacific Northwest (Pacific).

Please complete the following questionnaire to assist our evaluation of the Contractor’s past performance, and return via email no later than [Enter date] to [Enter point of contact information].

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):

Description of Services:

MARKET SEGMENT

MAGNITUDE

Annual Contract Value:

Total Contract Dollar Value:

COMPLEXITY

Number of FTEs:

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

Contractor performed on this contract as:

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)

Provided qualified Health Care Workers (HCW) 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 conditions of the contract.

Provided complete, current and accurate credentialing/privileging packages within established time frames IAW the terms and conditions of the contract.

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

Turnover Rate (CPARS “Management” Rating area)

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

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

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.

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

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.

As of 7 Feb 25