Attachment 4 - Relevant Experience Questionnaire.docx

RELEVANT EXPERIENCE QUESTIONNAIRE

A. CONTRACT INFORMATION

1. RFP TITLE

Virtual Medical Specialist Consultations

2.SOLICITATION NUMBER

19AQMM22R####

B. OFFEROR’S POINT OF CONTACT

3. NAME AND TITLE

4. NAME OF FIRM

5. TELEPHONE NUMBER

6. E-MAIL ADDRESS

C. PROPOSED TEAM MEMBERS

(Complete this section for the prime contractor and all key subcontractors as applicable)

PARTNER

SUBCON-TRACTOR

b c

RELEVANT EXPERIENCE QUESTIONNAIRE

D. PROJECTS WHICH BEST ILLUSTRATE QUOTER’S

RELEVANT EXPERIENCE FOR THIS CONTRACT

Complete one questionnaire for each project.

10. PROJECT IDENTIFIER

11. PROJECT TITLE AND LOCATION (City, State or Province, and Country)

12. YEAR COMPLETED

13. CLIENT'S INFORMATION

13a. CLIENT

13b POINT OF CONTACT

13c. POINT OF CONTACT TELEPHONE NUMBER AND EMAIL

14. DESCRIPTION OF PROJECT AND RELEVANCE TO THIS CONTRACT (Include scope, size, and cost)

Circle One

The following is provided to the Government to evaluate the quality of this Relevant Experience Questionnaire:

CPAR Print-Out // Past Performance Questionnaire

15. PROPOSED TEAM MEMBERS INVOLVED WITH THIS PROJECT (if any)

FIRM LOCATION (City, State or Province and Country)

ROLE

FIRM LOCATION (City, State or Province and Country)

ROLE

FIRM LOCATION (City, State or Province and Country)

ROLE

INSTRUCTIONS

Section A – Contract Information

Blocks 1-2 Solicitation Title and Number Information provided by the Government.

Section B – Quoter’s Point of Contact

Blocks 3-6 Provide name, title, name of firm, telephone number, and email address for a representative of the prime contractor or joint venture that the Department of State can contact for additional information.

Section C – Proposed Team

Blocks 7-9 Firm name, address, and role in supporting this contract. Provide the contractual relationship (i.e. prime, joint venture partner, subcontractor), firm name, full mailing address, and a brief description of the role that each firm will play in performance of this contract. List the prime contractor or joint venture partners first. Attach an additional sheet in the same format as Section C, if needed to list additional firms.

Note: Sections B and C (Blocks 3 – 9) only need to be completed once.

Section D – Projects Which Best Illustrate Quoters’s Relevant Experience for This Contract

Note: Section D (Blocks 10-15) will need to be completed for Relevant Experience project.

Select projects where multiple team members worked together, if possible, that demonstrate the team’s capability to perform work similar to that required for this contract. Complete one Section D for each project. Complete the following blocks for each project.

Block 10 – Project Identifier Start with “1” for the first project and number consecutively.

Block 11 – Project Title and Location Provide title and location of project or contract. For an indefinite delivery contract, the location is the geographic scope of the contract.

Block 12 – Year Completed Enter the year completed, if applicable. If any of the services are not complete, enter “Ongoing” and indicate the status in Block 14 (Description of Project and Relevance to this Contract).

Block 13 – Client’s Information

Block 13a – Client Client or user, such as government agency or installation, an institution, a corporation or private individual.

Block 13b – Point of Contact Provide name of a person associated with the client or the organization which contracted for the services, who is very familiar with the project and the firm's (or firms') performance.

Block 13c – Telephone Number and Email Self-explanatory

Block 14 – Description of Project and Relevance to This Contract Indicate scope, size, cost, principal elements and special features of the project. Discuss the relevance of the project to this contract. If an Quoter believes that any unfavorable information may be provided as a part of the reference check process, the Quoter should include a brief explanation of the circumstances pertaining to this data and the position of the Quoter in reference to these circumstances. If appropriate, the Quoter should indicate what steps have been included in this offer to prevent a recurrence of such situations.

Circle whether a CPAR print-out or Past Performance Questionnaire is provided to the Government to evaluate the quality of this project.

Block 15 – Proposed Team Members Involved As necessary, indicate which firms on the project team (listed in Section C – Proposed Team) were involved in the listed project, and a brief description of their role. List in the same order as specified in Section C.