Attachment 4- Past Performance Questionnaire.pdf

Attachment 4

FA301021R0001

Cardiovascular Center Staffing

PAST PERFORMANCE QUESTIONNAIRE

A. OFFEROR’S REFERENCE INFORMATION:

Contract Name and/or Number (include task order number(s) if applicable)

Company/Division Name to be evaluated

Address:

Point of Contact (POC):

Title of POC:

Telephone Number:

Email

Contractor performed as: Prime contractor Contractor performed as: Sub-Contractor Joint Venture Affiliate To/With _____________________

B. RESPONDENT INFORMATION: Please complete.

Contracting Activity/Customer

Address:

Telephone Number:

Email Address:

Point of Contact (POC):

Keesler AFB is in the process of soliciting offers from companies capable of providing:

(3) FTE Technicians - Cardiac Catheterization Laboratory, (2) FTE Registered Nurses (RN) - Cardiology Clinic/Cardiac Catheterization Laboratory, (1) FTE Nurse Practitioner (NP) - Cardiology Services, (1) FTE RN- Cardiology Clinic/Utilization Management/Team Lead, (1) FTE Medical Coder - Cardiovascular, and (1) FTE Picture Archiving and Communications System (PACS) - Cardiovascular

In order for the 81st Contracting Squadron to conduct its evaluation, we request that you complete the questionnaire below and e-mail a PDF file to priscilla.brown.5@us.af.mil, Contract Specialist, and jason.burdett.2@us.af.mil, Contracting Officer at 81 CONS, Keesler AFB. The due date for completed questionnaires is 01/13/2020 at 10:00 AM CST. Your completed questionnaire will become a part of the official source selection records. To be considered, the Past Performance Questionnaire shall be returned to the Contract Specialist in its entirety and by the due date and time specified above.

To confirm receipt of your completed/submitted questionnaires please contact Contract Specialist, Priscilla Brown by e-mail at priscilla.brown.5@us.af.mil.

Cardiovascular Center Staffing

Title of POC:

C. CONTRACT INFORMATION: Please complete.

Contract Name and/or Number

Task Order number:

Type of Contract:

Performance Period: (Base plus any options):

Performance Period for the task order:

Annual Contract Values:

Total Contract Dollar Value: (base plus any options)

Number of FTEs / Session-based:

Contract Description:

Contractor performed as: Prime contractor Contractor performed as: Sub-Contractor Joint Venture Affiliate To/With _____________________

What percentage of the contract was performed by the evaluated contractor, if available: ……...%.

Cardiovascular Center Staffing

Instructions:

Please provide ratings and comments regarding the Contractor’s performance in each area below using the following ratings.

RATING DEFINITION

Exceptional

Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Very Good

Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Satisfactory Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Marginal

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being evaluated reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

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

N/A Not Applicable

Exceptional Very Good

Satisfactory Marginal Unsatisfactory

N/A

A. QUALITY OF SERVICE AND PERFORMANCE

(1) The Contractor provided quality service that adhered to contract requirements, specifications, and standards of professional conduct.

(2) The Contractor consistently responded to problems and took appropriate action to correct performance.

(3) Did the contract involve hard to fill positions (specialty positions) or positions are remote locations? If so, Contractor successfully recruited and retained qualified Ancillary HCPs with minimal disruption.

B. MANAGEMENT

(1) Contractor was able to resolve customer complaints quickly and effectively.

(2) Contractor demonstrated an overall effective and quality management effort.

Cardiovascular Center Staffing

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

C. TIMELINESS/ SCHEDULE OF PERFORMANCE/SERVICES

(1) Contractor demonstrated ability to plan for and provide replacement candidates during the life of the contract to include pre-planned absences, unplanned illnesses, or an extended leave of absence.

(2) The Contractor consistently demonstrated an ability to quickly recruit and retain qualified HCPs in accordance with contract requirements and to avoid disruption of services and/or work schedule.

(3) Credentialing Packages (to include current and complete information) were presented in timely fashion to the applicable facility.

D. OTHER:

(1) Would you award this firm another contract? ( ) Yes ( ) No If you answered “No” provide an explanation. ____________________________________________________

(2) Was the contract terminated for default or cause? ( ) Yes ( ) No If you answered “Yes”, provide an explanation.___________________________________________________

(3) Has the Contractor been given a cure notice, show cause notice, suspension of progress payments in the last 3 years? ( ) Yes ( ) No If you answered “Yes”, provide an explanation and how many actions and if they were resolved:

(4) ADDITIONAL COMMENTS:

RESPONDENT SIGNATURE