Attachment 5 -Performance-Risk-Assessment Questionaire.docx
DOCX document 28 KB Posted
- Solicitation number
- W9114F23R0002
- Issued by
-
Department of the Army Medical Command
About this file
This document contains a performance risk assessment questionnaire for a federal contract to provide behavioral health and traumatic brain injury services to military medical facilities in Europe. The solicitation seeks qualified credentialed healthcare workers, both clinical and non-clinical, to support operations at Landstuhl Regional Medical Center and other overseas medical treatment facilities. The questionnaire is to be completed by an offeror and provides ratings on a scale of exceptional to unsatisfactory for the offeror's past performance in areas such as quality of services, timeliness, and business relations. Comments are required to support above average or poor ratings. The contracting office contact information is included for offerors to return the completed survey.
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Attachment 5 Performance Risk Assessment Questionnaire
Please provide your candid responses. The information that you provide will be used in the awarding of a federal contract. Therefore, it is important that your information be as factual, accurate and complete as possible to preclude the need for follow-up by the evaluators. If you do not have knowledge of or experience with the company in question, please forward this Questionnaire to the person who does. Thank you.
RETURN COMPLETED SURVEY FORM TO:
Medical Readiness Contracting Office (MRCO,EUR) Sarah Taylor and Matthew Elden Solicitation Number: W9114F23R0002 Phone Number: +49 6371 94647845 E-mail: Sarah.F.Taylor.civ@health.mil and Matthew.R.Elden.civ@health.mil A. EVALUATED CONTRACTOR’S INFORMATION: (To be completed by the Offeror)
Company/Organization Name being evaluated
Cage Code:
Point of Contact (POC):
Title of POC:
Address:
Telephone Number:
B. CONTRACT INFORMATION: (To be completed by the Offeror)
Contract Title/Description:
Contract Number:
Task Order Number if Applicable
Status (i.e. On-going, complete):
Contract Amount: total amount of base plus any options
Type of Contract
Performance Period being evaluated
Place of Performance:
Total Number of FTEs
Title of Position(s) provided by the Offeror
| Was work with a: | ||
| Commercial | Fed Gov’t Local/State Gov’t | entity. |
C. RESPONDENT INFORMATION:
Respondent’s Name:
Respondent’s Title
Company/Organization Name
Address:
Telephone Number:
| Evaluated Contractor Performed as: | |
| Prime Contractor _ | or Sub Contractor |
D. RATING INFORMATION:
Choose the number on the scale of 0 to 5 that most accurately describes the Offeror’s performance or situation. If you are unable to rate a question because it was not a requirement or you have no knowledge of the contractor’s performance under the question situation, then you should mark “Not Applicable” and do not include the specific question in the total number of questions answered at the bottom of the applicable section. If the question situation would be considered a part of the required performance under this contract, but the contractor have experience in the area, then mark “0” and include it in the total number answered at the bottom of the applicable section.
| RATING |
| DEFINITION |
| Exceptional = 5 |
| Performance meets contractual requirements and exceeds many requirements to |
the government’s benefit. (Risk Level: Very Low)
| Very Good = 4 |
| Performance meets contractual requirements and exceeds some to the |
government’s benefit. (Risk Level: Low)
| Satisfactory = 3 |
| Performance meets contractual requirements. (Risk Level: Moderate) |
Marginal = 2 Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the Contractor has not yet implemented satisfactory corrective action. (Risk Level: High)
Unsatisfactory = 1 Performance does not meet contractual requirements recovery is not likely in a timely manner. Contractor’s corrective actions to date are ineffective (Risk Level:
Very High)
| Unknown = 0 |
| The Offeror has little/no relevant past performance upon which to base a |
meaningful performance risk prediction. (Risk Level: Unknown)
E. PERFORMANCE EVALUATION QUESTIONS:
Quality of Services
Performance Rating
(1) The Contractor provided quality services that adhered to contract requirements, specifications, and standards of professional conduct.
(2) The Contractor provided quality personnel that met or exceeded the required qualifications.
(3) The Contractor demonstrated an overall effective and quality management effort.
(4) The Contractor maintained an effective on-going Quality Control Plan to provide for monitoring, analyzing, and improving quality contract performance.
Performance Rating Total
Performance Rating Total Divided by total number of questions answered
Overall Rating
Performance Rating
(1) The Contractor successfully achieved fill-rates established by the contract.
(2) The labor turnover in personnel and other labor categories (to include contracted health care providers) was minimal and did not adversely affect Contractor Performance.
(3) The Contractor consistently demonstrated an ability to quickly recruit Healthcare Workers (HCWs) on time to meet the Government’s needs.
(4) The Contractor demonstrated the ability to retain HCWs to support contract/task order requirements so that work schedules would not be disrupted.
(5) The Contractor demonstrated the ability to plan for and provide replacement candidates to include pre-planned absences, unplanned illnesses, or an extended leave of absence.
(6) Credentialing Packages (to include current and complete information) were presented in timely fashion to the applicable facility.
Performance Rating Total
Performance Rating Total Divided by total number of questions answered
Overall Rating
Timeliness of Performance/Services Business Relations
Performance Rating
(1) The Contractor had the ability to respond effectively to contract performance issues.
(2) If applicable, the Contractor acted in accordance with any “Non-Compete Clause” Terms and Conditions of the contract.
(3) The Contractor maintained an open line of communication so that the Contracting Officer’s Representative (COR) was apprised of technical and cost issues.
(4) The Contractor cooperated with the Government in providing flexible, proactive, and effective solutions to critical contract issues.
(5) The Contractor provided proactive and effective management of its subcontractors, if applicable.
(6) The Contractor was able to resolve customer complaints quickly and effectively.
Performance Rating Total
Performance Rating Total Divided by total number of questions answered
Overall Rating
F. OTHER:
(1) Would you award this firm another contract? (__) Yes, ( ) No. If you answered “No” provide an explanation.
| (2) Was a cure notice | ; show cause notice_ | ; suspension of progress payments, |
| and/or | termination for default issued to this firm during performance of this contract? If you answered “Yes”, provide an explanation. | |
| N/A |
(3) Based upon the information you provided and using the definitions provided in the evaluation criteria above, please select the overall performance rating for this Contractor.
Exceptional Very Good Satisfactory Marginal Unsatisfactory Unknown
COMMENTS: (ALL Unsatisfactory, Marginal, Very Good, or Exceptional Ratings require comments to support the same. Failure to provide comments may render the questionnaire void and will not be evaluated by the Government):
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