Attachment 3 - Past Performance Questionnaire HT0011-22-R-0022.docx

Solicitation No.: HT0011-24-R-0022 Past Performance Questionnaire Solicitation No.: HT0011-24-R-0022 Past Performance Questionnaire

Recent and Relevant Past Performance Questionnaire

1. Past Performance Assessment. The Defense Health Agency’s Contracting Office, Defense Health Agency, Professional Services - Contracting Division (PS-CD), is soliciting competitive offers for the acquisition of non-personal services for Pharmacy High Density Storage – Enterprise (PHDS-E) for the Defense Health Agency (DHA) Pharmacy Operations Division (POD), Pharmacy Informatics Integration Branch.

We are requesting that you complete this questionnaire.

PLEASE RETURN THIS COMPLETED QUESTIONNAIRE TO THE OFFEROR. THE OFFEROR WILL INCLUDE IT AS PART OF ITS OFFER.

If you need more space than that provided, please attach additional pages. Responses will be treated as source selection sensitive information. If you have any questions contact Defense Health Agency, Professional Services – Contracting Division (PS-CD), Contract Specialist: peichang.wang.civ@health.mil

*NOTE: IT IS THE RESPONSIBILITY OF THE OFFEROR TO ENSURE ALL PAST PERFORMANCE QUESTIONNAIRES ARE SUBMITTED TO THE GOVERNMENT BY THE SOLICITATION CLOSING DATE AND TIME.

2. Contract Information. Please complete the following:

Contractor:

Contract Number:

Period of Performance:

Contract Type: Fixed-Price; Labor Hour or Time and Material; Cost-Reimbursement (CPFF, CPAF, CPIF, etc.)

Describe the Products or Services:

3. Contract Relevancy. For comparison with the size and scope of the acquisition, please provide the following information pertaining to the contract identified in Section 2 above:

A. Size: $______________ per year in contract services.

B. Scope: As the Customer, does the contract you are providing a past performance evaluation for (Check all that apply):

______ Have experience in supporting DoD network & systems engineering related engineering and operational issues

______ Have experience in performing system and endpoint architecture, engineering, and design within the DoD network

______ Have experience in performing Identity Engineering

______ Have experience in engineering and supporting Public Key Infrastructure (PKI) and Public Key Enablement (PKE)

______ Have experience providing 24 hour operational support and have experience supporting a global user base across all time zones

______ Have experience identifying and resolving integration issues between disparate Healthcare IT systems and technologies

______ Have experience collaborating with multiple vendor partners all working toward common Governmental goals

______ Have experience in DoD enterprise level IT system design and software development

______ Have experience with DoD-compliant Information Assurance (IA) controls

______ Have knowledge of HIPAA (Health Insurance Portability and Accountability Act) and Privacy Act concepts and the application of requirements as they relate to medical systems

______ Have personnel that are familiar with and the application of provisions contained in DoDD 8140

______ Have personnel who will be able to obtain and maintain DoD approved baseline certifications

______ Have experience and capabilities in meeting National Institute of Standards and Technology (NIST) and Risk Management Framework (RMF) cybersecurity

4. Performance Assessment Values

5 - Outstanding. Performance meets contractual requirements and exceeds many requirements, to the Government’s benefit. Contractual performance of the element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

4 - Excellent. Performance meets contractual requirements and exceeds some requirements, to the Government’s benefit. Contractual performance of the element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

3 – Good. Performance meets contractual requirements. Contractual performance of the element being assessed contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

2 - Satisfactory. Performance barely meets some contractual requirements. Contractual performance of the element being assessed 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.

1 - Unsatisfactory. Performance does not meet some or most contractual requirements and recovery is not likely in a timely manner. Contractual performance of the element being assessed contains serious problem(s) for which the contractor's corrective actions appear or were ineffective.

0 - Not Applicable. Unable to provide a score. Performance in this area not applicable to effort assessed.

5. Assessment Elements. Please select/circle the appropriate performance assessment value for each item on the questionnaire and provide supporting narrative.

A. Cost Control. Rate the contractor’s effectiveness in forecasting, managing, and controlling costs (including reporting and analyzing variances) and ability to deliver at the agreed-to cost/price. Provide reasons for changes to the contract value (e.g., scope changes, overrun/underrun, Government-imposed schedule changes).

5 4 3 2 1 0

Comments:

B. Schedule. Rate the contractor’s ability to deliver according to the agreed-to schedule. What were the causes of any schedule variances?

5 4 3 2 1 0

Comments:

C. Mission Requirements. Rate the contractor’s ability to provide a product or service that met your mission requirements.

5 4 3 2 1 0

Comments:

D. Quality. Rate the contractor’s ability to provide a product or service that met your required level of quality. Assess the contractor’s conformance to contract requirements, specifications, and standards of good workmanship (e.g., commonly accepted technical, professional, environmental, or safety and health standards.)

5 4 3 2 1 0

Comments:

E. Subcontract Management. Rate the contractor’s ability to meet the goals of the subcontracting plan, to include the ability to timely award and manage subcontracts.

5 4 3 2 1 0

Comments:

F. Business Relations. Rate the contractor’s ability to integrate and coordinate all activities needed to execute the contract, specifically the timeliness, completeness, quality of problem resolution, corrective action plans, the contractor’s history of reasonable and cooperative behavior, customer satisfaction, and its ability to submit accurate invoices in a timely manner.

5 4 3 2 1 0

Comments:

G. Management of Personnel. Assess the contractor’s performance in selecting, retaining, supporting, and replacing—when necessary— personnel.

5 4 3 2 1 0

Comments:

6. Other References. If you are aware of any other contract or a Point of Contact (POC) who is familiar with the contractor’s performance under this contract, please identify.

Name, Phone, and E-Mail Address:

7. Assessor Information. Please provide the following information about yourself:

Name:

Title:

Address:

Phone Number:

E-Mail Address:

Reference Signature: _______________________________

[Note: Either physical (pen and ink) or CAC enable electronic signatures are acceptable]

Date: _________________

Thank you for your assistance.