Attachment 5- Past Performance Questionnaire.xlsx

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Attached to
Virtual Medical Specialist Consultations
Solicitation number
19AQMM22R0152
Issued by

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This document contains a past performance questionnaire for a contractor providing virtual medical specialist consultations. The questionnaire collects information about the contractor's previous relevant contracts, including contract details such as period of performance, value, and description of requirements. It also contains evaluation criteria and ratings for assessing the contractor's past performance in areas such as technical services, quality of services, price and cost control, business relations, and customer satisfaction. The completed questionnaire is to be submitted to the U.S. Department of State by the specified due date as part of an upcoming solicitation for virtual medical specialist consultation services to support the Bureau of Medical Services.

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Other files

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Attachment 3 - Template for Vendor Questions.xlsx XLSX spreadsheet
Attachment A - Quality Assurance Surveillance Plan.doc DOC document
Attachment 1- Pricing Tables.xlsx XLSX spreadsheet
Attachment 4 - Relevant Experience Questionnaire.docx DOCX document
Virtual Medical Consultation Specialist RFP - July 2022 V2 Draft RFP.pdf PDF
Draft 19AQMM22R0152.pdf PDF
Attachment 2- Virtual Consultation Operational Workflows.docx DOCX document
Attachment 6 - Subcontracting Plan Template.docx DOCX document

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Past Performance Questionnaire

PAST PERFORMANCE CUSTOMER SATISFACTION SURVEY
Introduction: The United States Department of State (DOS) is currently conducting a competitive procurement for Virtual Medical Specialist Consultations to support the Bureau of Medical Services (MED). The scope of this effort is to provide real-time medical specialist consultations for emergency, urgent, and non-urgent medical care conducted via a modern, secure telehealth platform provided by the Offeror.

Offerors have been requested to identify Government agencies or commercial vendors with whom it is currently or has been recently under contract, to serve as potential references on its past performance record. You are being asked to complete this Past Performance Questionnaire (PPQ).

This PPQ is being submitted to reflect work performed by [Insert Name of Offeror Submitting Response to DOS Requirement]

Instructions: Please complete all areas of this form indicated in light yellow.
PART I - CONTRACT INFORMATION
a. Contractor:
b. Customer Name (Federal Agency or Other):
c. Technical Point of Contact Information
i. Name:
ii. Telephone Number:
iii. Facsimile Number:
vi. Position Title:
d. Contract Number:
e. Type of Contract(Select responses from drop down menu)
i. Competitive or Non-Competitive:
ii. Firm-Fixed-Price, Cost-Plus, Time-and-Materials/Labor Hour, Hybrid, or Other:
f. Contract Period of Performance:
h. Initial Contract Value: $
i. Current (or Completed) Contract Value: $
j. Brief Description of the Contract Requirement:
PART II - GOVERNMENT PAST PERFORMANCE/CUSTOMER SATISFACTION EVALUATION
EVALUATION CRITERIA
EXCELLENT: Indicates the Contractor's performance within the area of evaluation clearly and consistently exceed contractual requirements.
SATISFACTORY: Indicates the Contractor's performance within the area of evaluation met the contractual requirements.
MARGINAL: Indicates the Contractor's performance within the area of evaluation experienced minor problems for which solutions were satisfactory.
UNACCEPTABLE: Indicates the Contractor's performance within the area of evaluation experienced serious problems. The Contractor is/was in danger of being unable to satisfy contractual requirements and timely recovery is not likely or did not occur.
EVALUATION AREA 1: TECHNICAL SERVICES
(Select the rating that applies from drop down menu)
Overall ability to conduct virtual medical consultations in a timely manner:
Overall ability to manage telehealth program:
Overall efficacy of telehealth platform:
Overall understanding of and ability to maintain quality of program management:
Overall ability to coordinate and integrate work to prevent unnecessary duplication of services and minimize disruptions to contract timelines:
EVALUATION AREA 2: QUALITY OF SERVICES
(Select the rating that applies from drop down menu)
Overall quality of medical services provisioned:
Level of patient outcome improvement due to Contractor intervention:
EVALUATION AREA 3: PRICE/COST CONTROL
(Select the rating that applies from drop down menu)
Quality, completeness, and accuracy of price/cost proposals/invoices:
Ability to perform within negotiated costs/prices:
Ability to provide innovative solutions that resulted in cost savings:
EVALUATION AREA 4: BUSINESS RELATIONS
(Select the rating that applies from drop down menu)
Ability to effectively manage contract:
Ability to choose and manage quality subcontractors/team partners:
EVALUATION AREA 5: CUSTOMER SATISFACTION
(Select the rating that applies from drop down menu)
Maintains a single effective point of contact to manage and resolve problems:
Effectiveness in interfacing with personnel in your organization:
Overall ability to resolve performance issues:
EVALUATION AREA 7: OVERALL CONTRACT PERFORMANCE
(Select the rating that applies from drop down menu)
Based on this contractor's overall performance, would you award this contractor another contract?
COMMENTS (Please include any additional comments concerning the past performance of the contractor):
Thank you for completing this past performance evaluation. Please email the completed survey to the following address:
U. S. Department of State
Office of the Procurement Executive
ATTN: Kelley Kershner and Annie Harlow
E-MAIL ADDRESS: KershnerK@state.gov and HarlowAL@state.gov

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