Attachment 2 - Past Performance Questionnaire Sheet.docx

Solicitation HT940626QE013 Attachment 2

Past Performance Questionnaire

The Defense Health Agency is conducting an acquisition for the services noted below. The contractor has identified you as a reference to validate past performance.

Solicitation HT940626QE013 is for Neonatologist and Neonatal Nurse Practitioner (NNP) coverage services in support of Naval Medical Center Camp Lejeune, NC (NMCCL).

Please complete the following questionnaire to assist our evaluation of the contractor’s past performance, and return via email no later than 1000, Eastern Time on Wednesday, 15 July 2026 via email to derek.j.bell.civ@health.mil. Please reference “Solicitation HT940626QE013” in the subject of the email.

RESPONDENT INFORMATION (to be completed by the Contractor):

Contracting Activity/Customer:

Point of Contact (POC):

Title of POC:

Telephone:

Email:

CONTRACT INFORMATION (to be completed by the Contractor):

Contract Number:

Task Order Number:

Performance Period: (Base plus any options):

Description of Services (included labor categories and number of FTEs/labor category):

MARKET SEGMENT

COMPLEXITY

Number of FTEs:

Number of Credentialed FTEs:

Number of Privileged FTEs:

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

All information from here down shall be completed by the Reference POC. The Reference POC shall also verify the information completed by the Contractor and make any necessary corrections before signing this form.

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.

(NA) Not Applicable – Unable to assess the area.

Overall Fill Rate (CPARS “Quality” Rating Area)

Provided qualified contracted personnel IAW the terms and conditions of the contract.

Ensured that qualified contracted personnel remained filled IAW the terms and conditions of the contract.

Recruited, placed and retained qualified contracted personnel 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)

Provided qualified contracted personnel on time IAW the terms and conditions of the contract.

Provided complete, current and accurate qualifying packages within established time frames 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 contracted personnel 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 contractor.