Attachment 5 - Past Performance Questionnaires.docx

RFP 6923G227R000002

Attachment 5 PAGE 1 OF 1

Medical, dental, counseling, pharmacy services for USMMA

PAST PERFORMANCE EVALUATION QUESTIONNAIRE(PPQ)

MAINTENANCE PERFORMANCE INFORMATION

SECTION A: Contractor Information (to be completed by the offeror)

1. Contractor’s Title, Name and Address:

2. Point of Contact:

3. Phone Number (with area code):

4. Contract Number:

5. Description / Explanation of contract services provided:

SECTION B: Respondent Information: (To be completed by Respondent, i.e., Commercial Sector or Government)

1. Respondent’s Title, Name and Address:

2. Phone Number & email address:

3. Contract Specifics:

a. Contract Number:

b. Contract Type: Firm-Fixed-Price Indefinite Quantity/Task Order Cost-Reimbursement

c. Start Date / End Date:

d. Original Contract Amount: $

e. Current Contract Value: $

Please e-mail the completed questionnaire by 2:00 pm EDT 11/11/26 to: durba.ray@dot.gov; cc NarineA@usmma.edu; Brian.Wiley.ctr@dot.gov

PAST PERFORMANCE EVALUATION OFFEROR’S REFERENCE QUESTIONNAIRE

1. Complete this questionnaire using the grading system explained below. Your assessment should only consider performance for which the contractor is responsible and accountable. Each offeror shall be assigned one the following ratings:

(HS) HIGHLY SATISFACTORY/HIGH CONFIDENCE - Performance meets contractual requirements and exceeds many (requirements) to the Government's benefit. The contractual performance of the element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

(S) SATISFACTORY/CONFIDENCE - Performance meets contractual requirements. The contractual performance of the element being assessed contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

(U) UNSATISFACTORY/NO CONFIDENCE - Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element being assessed contains serious problem(s) for which the contractor's corrective actions appear or were ineffective.

(N) NOT APPLICABLE/UNKNOWN CONFIDENCE - Unable to provide a score. Performance in this area is not applicable to effort assessed.

2. Please circle the rating, the appropriate letter, for each item on the questionnaire, which most accurately describes the contractor’s performance. Provide frank, concise comments or supporting narrative explanations in the spaces provided. When responding to the descriptive statements, select the answer, which most accurately describes the contractor’s performance or situation. You may use additional sheets if more space is needed.

PAST PERFORMANCE QUESTIONS

a. Quality of services received was satisfactory. Any dissatisfaction, please explain.

HS S U N

b. Quality of maintenance provided was satisfactory. Any dissatisfaction, please explain.

HS S U N

c. Contractor met established work schedules to complete all performance requirements. (Yes/No). What were the causes of any schedule variances? (Explain)?

HS S U N

d. Randomly performed required 100 % surveillance procedures (Yes/No)? Discrepancies were identified by Periodic or Customer complaint methods? (Circle one). Did offeror re-perform the service promptly?

HS S U N

N__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

e. Was money deducted for services not received? If yes, please explain No____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

f. Had the necessary manpower to perform in an efficient and timely manner.

HS S U N

g. Adequately complied with all Federal and mandated policy, rules and regulations requirements.

HS S U N

Yes______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

h. Identified problems in advance and when necessary, took positive and effective corrective actions.

HS S U N

i. Offeror provided effective Quality Control/Inspection procedures.

HS S U N

j. Offeror has a history of recurring problems? (Yes/No). If yes, please explain.

k. Met terms of the contract and within the contractual price.

HS S U N

l. Responded timely and professionally to your needs in performing responses.

HS S U N

m. Responsive to the quality program by identifying, correcting, and preventing initial and recurring contract discrepancies.

HS S U N

n. List the contractor’s documented strength and weakness in performing the contract requirements and rate them.

o. Are there any indications that the contractor has financial concerns that would jeopardize contract performance? (If YES, please explain in “Remarks” section)

HS S U N

No_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

p. Contract managers have sufficient authority to make decisions and take actions necessary to ensure services were performed.

HS S U N

Yes________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Q. Were there any problems with employees or subcontractors payments? (Yes/No). Explain any negative response.

r. Was it ever elected not to exercise an option due to the contractor’s poor performance? (Yes/No). If yes, please explain.

s. Do you have any reservations in awarding another contract to the offeror? (Yes/No). If yes, please explain.

t. Select one rating which most accurately describes the contractor’s overall performance on your contract.

HS S U N

Name:__________________________ Signature: ____________________ Attachment 4 image1.png