Attachment 5 - Past Performance Questionnaire 08.05.docx

ATTACHMENT 5 – Past Performance Questionnaire

PART ONE: INSTRUCTIONS

The company who has provided you with this form is proposing on a Department of Homeland Security, Customs and Border Protection solicitation. Past Performance is an important part of the evaluation criteria for this acquisition, so your input is very important. Please provide an honest assessment and return the questionnaire to the offeror (requesting company) by e-mail and carbon copy (CC) peter.a.giambone@cbp.dhs.gov and SHAUNGALEN.SAAD@CBP.DHS.GOV. The offeror shall then submit the Past performance questionnaire and responses to the Elements addressed in the Request For Proposal (RFP) by Close of Business, 1PM EST August 21st, 2020 with the offeror’s Phase 1 Submission.

PART TWO: GENERAL INFORMATION

70B06C20R00000044

1. OFFEROR’S INFORMATION

Name and Address:

Phone Number:

Email Address:

2. CONTRACT NUMBER

3. CONTRACT VALUE ($)

4. CONTRACT AWARD DATE

5. CONTRACT COMPLETION DATE

6. COMPLEXITY OF WORK (Circle One)

DIFFICULT / ROUTINE

7. CONTRACT TYPE

8. CUSTOMER ORGANIZATION

8a. CUSTOMER EVALUATOR Name:

Title:

Phone Number:

Email Address:

9. DESCRIPTION OF SERVICES

PART THREE: OFFEROR PERFORMANCE RATING

On the following pages, please summarize the Offeror’s performance for each rating factor as Excellent/Satisfactory/Good/Unsatisfactory by placing an “X” under the appropriate heading.

Satisfaction ratings are defined below and should be used as a reference in assessing performance:

RATINGS DEFINITIONS

Neutral (only applies to Prior Experience) The vendor does not have record of relevant past performance or information is not available. The vendor will not be evaluated favorably or unfavorably

C

(a) Performance of services

(b) Delivery of reports or other documentation

(c) Resolution of system deficiencies

PART THREE: OFFEROR PERFORMANCE RATING CONTINUED

1. Has this contract been partially or completely terminated for default or convenience?

If yes, please explain (e.g. inability to meet price, performance, or delivery schedules - also include contract number, name, address, and phone number of Terminating Contracting Officer - TCO).

COMMENTS:

PART FOUR: EVALUATOR’S CERTIFICATION

I HEREBY CERTIFY THAT THE INFORMATION IN THIS FORM IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

SIGNATURE OF EVALUATOR

TITLE OF EVALUATOR

PART FIVE: OFFEROR’S RESPONSE (Filled out by the offeror) Please provide any additional past performance information that was not covered above, regarding this referenced contract, which addresses the elements requested in the solicitation. Information already addressed above shall not be restated. The Elements are listed below:

· Successful past performance providing MRO and HHS-Certified Laboratory Services to Drug-Free Workplace Program with similar work volumes within three years immediately prior to the date of the Offeror’s proposal.

· Successful past performance providing Medical services within three years immediately prior to the date of the Offeror’s proposal.

· Successful past performance in the same or similar requirements identified in the SOW and listed below within three years immediately prior to the date of the Offeror’s proposal.

Past performance with government entities is preferred. Offeror shall demonstrate favorable past performance in contracts with similar size, scope and complexity providing the following services:

· Employee Medical Services such as Examinations, Consultations, Fitness for Duty Examinations (FFDE) and Return to Work cases

· Medical Documentation Reviews to include clinical opinions and requirement recommendations

· Drug-Free Workplace Program Administration to include specimen collection, supplies, laboratory analysis and medical review officer oversight

· Candidate Medical Examinations, Fitness Tests and Consultations