Attachment 5- Past Performance Questionnaire.xlsx
XLSX spreadsheet 22 KB Posted
- Attached to
- Virtual Medical Specialist Consultations
- Solicitation number
- 19AQMM22R0152
About this file
This document contains a past performance questionnaire and details of a solicitation for virtual medical specialist consultations. The past performance questionnaire is for contractors to provide references on prior work completed for government agencies or commercial clients. It requests information on contract period of performance, value, description of work, and performance ratings in areas such as technical services, quality, cost control, business relations, and overall performance. The solicitation seeks proposals to provide real-time medical specialist consultations via telehealth for emergency, urgent, and non-urgent care for the Department of State. Proposals are due by September 9, 2022. The solicitation number is 19AQMM22R0152 and the opportunity can be found on SAM.gov.
View the file
Other files
Show all 18
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
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 |
&1#&"Times New Roman"&10&K000000SENSITIVE BUT UNCLASSIFIED
File details come from the government source that posted it. Updated .