Attachment 2 - PPQ IONM Services.docx

Attachment 3 Past Performance Questionnaire

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

Request for Proposal is for is for non-personal services, Intraoperative Neurophysiologic Monitoring services for the 60th Medical Group, David Grant Medical Center, Travis AFB, CA.

Please complete the following questionnaire to assist our evaluation of the contractor’s past performance and return via email no later than 12:00 pm PST on 16 January 2025 via email to tyler.d.smith100.civ@health.mil and Jeffrey.p.collins20.civ@health.mil. Please reference “HT941025Q2023” 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):

Relevance:

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.

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

On Site Personnel Reliability/Qualified

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

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

Contractor demonstrated ability to plan for and provide replacement staff during the life of the contract to include preplanned absences, unplanned illnesses, or an extended leave of absence.

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

Quality & Management

Contractor provided quality service that adhered to the contract requirements.

Contractor consistently responded to problems and took appropriate action to correct performance.

Contractor demonstrated an overall effective and quality management result.

Contractor cooperated with the Government in providing flexible, proactive, and effective solutions to critical contract issues.

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.