Attachment 4 Past Performance Questionnaire 08152025.docx

PAST PERFORMANCE QUESTIONNAIRE

PART ONE: INSTRUCTIONS

The company who has provided you this form is proposing on a Defense Health Agency Support Services contract for their Office of Small Business Programs. Past performance is an important evaluation criterion for the acquisition, so input from previous customers of the offeror is very important. We would greatly appreciate you taking the time to complete this form. Note: Offerors may be debriefed on performance evaluation information obtained from references. However, the names of the individual(s) providing information will not be disclosed.

Please provide your assessment and return the completed form (or equivalent) directly to the Defense Health Agency Contracting Officer in time for evaluation beginning on or before September 1, 2025.

PRIOR TO SUBMITTAL PLEASE CONVERT THE DOCUMENT TO ADOBE PDF COMPLIANT VERSION WITH SIGNATURES.

Vicki L. Whiteman Defense Health Agency Contracting Activity Professional Services Contracting Division 7700 Arlington Blvd.

Falls Church VA 22042 E-Mail: vicki.l.whiteman.civ@health.mil Copy to Contract Specialist Mary Anne Young: mary.a.young138.ctr@health.mil Subject: “Solicitation HT001125RE003–PP Questionnaire”

PART TWO: GENERAL INFORMATION

1. OFFEROR’S NAME AND ADDRESS 2. CUSTOMER ORGANIZATION NAME AND ADDRESS

3. CONTRACT NUMBER: 2a. EVALUATOR

PHONE NO:

5. CONTRACT OR ORDER AWARD DATE: 6. CONTRACT OR ORDER COMPLETION DATE

(Include Extensions):

(Check One Response):

Attachment 4 - PP Questionnaire

HT001125RE003

ATTACHMENT 4 -Past Performance Questionnaire

PART TWO: GENERAL INFORMATION (continued)

8. a. Primary Contractor Subcontractor

9. INDICATE GEOGRAPHIC DISTRIBUTION OF SERVICES 10. NUMBER OF USERS

/LOCATIONS SERVICED

Local; Nationwide; Worldwide BY THIS CONTRACT:

· TYPE AND EXTENT OF SUBCONTRACTING SUPPORT (Complete this item only if subcontracting support was used by the offeror):

· BRIEF DESCRIPTION OF YOUR CONTRACT REQUIREMENTS:

PART THREE: OFFEROR PERFORMANCE RATING

Please rate the offeror’s performance in each of the evaluation factors/subfactors listed on the following pages. Determine the adjectival rating that most nearly represents your experience with this offeror and indicate your assessment by placing any “X” under the appropriate heading.

Evaluation factors include:

a. QUALITY OF SERVICES

b. OFFEROR PERSONNEL

c. TIMELINESS OF PERFORMANCE

d. CUSTOMER SATISFACTION Adjectival ratings are defined as follows:

EXCELLENT = Offeror performance exceeded customer expectations or contract requirements, and routinely provided significant or worthwhile features or benefits.

Attachment 4 - PP Questionnaire

1. Contractor’s overall performance and management of contract requirements

2. Contractor’s ability to satisfy contract technical work requirements

3. Contractor’s process for controlling work ( receiving, validating, scheduling and tracking individual contract work requests)

4. Contractor’s Quality Control System (ability to identify and correct cause of non-conforming work or work processes)

5. Contractor’s Safety Program (record of safe operation)

Comments:

1. Project Manager (ability to effectively manage the contract)

2. Supervisors (ability to supervise contract work)

3. Contractor’s Work Staff, including Subcontractors (adequately trained; possess necessary skills; perform effectively in accordance with contract terms; etc.)

Comments:

1. Timely contract start-up (acquired required licenses, training, administrative clearances, equipment, etc. and prepared to start performance by contract start date)

2. Timely performance of contract work

3. Timely performance of administrative actions (e.g. submission of required reports, records, and other data submissions)

4. Timely payments (payroll and subcontractor payments)

Comments:

PP Questionnaire

HT001125RE003

ATTACHMENT 4 - Past Performance Questionnaire

1. Contractor’s commitment for providing resources as necessary to resolve user problems and questions

2. Contractor’s ability to relate effectively to customer staff

3. Contractor’s ability to meet contract goals and objectives

4. Contractor’s positive and effective response to unexpected change and urgent requirements

5. In your judgment, does the Contractor display integrity (appearing to adhere to a code of sound moral principals, uprightness, and honesty)?

6. WOULD YOU CONTRACT WITH THIS CONTRACTOR AGAIN FOR SIMILAR

SERVICES?

Comments:

COMMENTS:

PART FOUR: EVALUATOR

The evaluation was performed by:

Name/Title of Evaluator: Signature of Evaluator: Date: Phone No. and Email Address

Attachment 4 - PP Questionnaire