Attachment 8 Past Performance Questionnaire.pdf

Attachment 8 FA487721R0001

PRESENT / PAST PERFORMANCE EVALUATION QUESTIONNAIRE

CLINICAL HEALTHCARE SERVICES, DAVIS-MONTHAN AFB

SOLICITATION NO: FA4600-21-R-0001

FORM COMPLETION INSTRUCTIONS: Please fill this questionnaire in by hand or type, and please email the results to the Contracting Officer, Jeremy Dedmon at jeremy.dedmon@us.af.mil and to the Contract Specialist, Roxanne Elfering at roxanne.elfering@us.af.mil. Email submissions are preferred.

Please direct questions to Roxanne Elfering at 520-228-5448 or Jeremy Dedmon at 520-228-5448. Your Participation is greatly appreciated.

PLEASE RETURN NO LATER THAN: 19 January 2021, at 10:00 AM (Mountain Standard Time)

Your assistance is respectfully requested in providing information on the attached performance questionnaire.

The importance of your opinion cannot be overstated. This survey measures the present/past performance of prospective offeror for providing Clinical Healthcare Services at Davis-Monthan AFB, AZ.

(1) Name of Contractor questionnaire is being completed for:

(2) Contract Number:

(3) Role Contractor Played in Prior Contract Prime Subcontractor Joint Venture Team Member

(4) Proposed Role in Pending Contract Prime Subcontractor Joint Venture Team Member

(5) Length of time your agency/firm has been involved with the Offeror:

(6) Contract Type and Value:

(7) Description of Service:

(8) Is performance on this contract being reported in CPARS Yes No

(9) Name of Agency/Company completing questionnaire:

(11) Name/Title of person completing questionnaire:

(12) Phone number/email of person completing questionnaire:

(13) Date questionnaire is being completed:

(14) What were the scope and major functions performed under this contract (i.e. project size)?

RATING SCALE: Please use the following ratings to answer the questions on page 2 Rating Definition

Exceptional Performance meets contractual requirements and exceeds many to the Government’s benefit.

The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Very Good Performance meets contractual requirements and exceeds some to the Government’s benefit.

The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Satisfactory Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Marginal Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Unsatisfactory Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Neutral No record exists.

N/A (Not applicable) should be used if the ratings are not going to be applied to a particular area for evaluation.

NOTE: For any ratings less than satisfactory rating, please provide explanation in Remarks section below.

CONTRACTOR PAST PERFORMANCE EVALUATION SURVEY

FOR SERVICES

N /A

N eu tr al

U n sa ti sf ac to ry

M ar gi n

S at is fa ct or y

V er y G oo d

E xc ep ti on

1.)Management Effectiveness:

a. Contractor provided experienced managers and supervisors with technical and administrative abilities to meet contract requirements.

b. The Contractor provided qualified HCW’s IAW the terms and conditions of the contract requirements.

c. Recruited, placed and retained qualified HCW’s with minimal disruption for hard-to-fill (specialty) positions.

d. The Contractor utilized personnel that were appropriate to the effort performed.

e. Contractor demonstrated effective management over the effort performed.

f. Contractor maintained an open line of communication so that the Contracting Officer’s Representative (COR) and/or Contracting Officer were apprised of any schedule issues.

g. Contractor demonstrated effective management of its subcontractor(s) and or teaming partner as it relates to the contract

h. Contractor’s overall management effectiveness

PLEASE PROVIDE COMMENTS ON LAST PAGE IF RATED ABOVE OR BELOW SATISFACTORY

2.) Quality of Service and Workmanship:

a. Contractor provided professional staff.

b. Contractor maintained quality of staff care

c. Contractor provided a complete and accurate qualifying package for each HCW in accordance with the terms and conditions of the contract.

d. Tasks required under this effort were performed in a timely manner and in accordance with the period of performance of the contract.

e. Contractor presented information and correspondence in a clear, concise, and businesslike manner.

g. Contractor promptly notified the COR and/or Contracting Officer in a timely manner regarding urgent issues.

3.) Manpower Efficiencies

a. Contractor provided new hires in a timely manner

b. Labor turnover in key personnel labor categories was minimal and did not adversely affect Contractor performance.

c. Contractor proposed qualified personnel to fulfill the requirements of the contract without frequent turnover and minimal operation disruption.

d. Contractor illustrated the capability to manage large workforce at one location (25+ employees)

4.) Quality Control

a. Contractor provided an adequate quality control plan

b. Contractor adhered to its quality control plan

c. Contractor documented its quality control checks/corrective actions

d. Contractor cooperated with the Government in providing flexible, proactive, and effective recommended solutions to critical program issues.

e. Contractor’s ability to address performance problems

f. Contractor’s overall quality control

PLEASE PROVIDE COMMENTS ON LAST PAGE IF RATED ABOVE OR BELOW SATISFACTORY

5.) Customer Satisfaction

a. Services provided adequately met the needs of the program.

b. Contractor was able to perform with minimal direction from the COR or the Contracting Officer.

c. Contractor's reasonableness, cooperation, and commitment to customer satisfaction

d. I am satisfied with the performance of the Contractor under this effort.

PERFORMANCE SUMMARY:

Would you award this firm another contract? Yes No If you answered No provide an explanation in the additional comments section

How many Full Time Equivalents (FTE) are on the contract for each specialty? Please populate this information in the Specialty log provided below.

SPECIALTY LOG

Specialty Number of FTE(s)

Aerospace Medicine Provider

Allergist

Allergist Technician

Beneficiary Services Representative

Biomedical Equipment Technician

Certified Medical Technician

Chiropractic Technician

Chiropractor

Clinical Nurse – Behavioral Health

Clinical Nurse – Family Practice

Clinical Nurse – Flight Medicine

Clinical Nurse – Occupational

Clinical Nurse – Pediatrics

Clinical Nurse – Women’s Health

Clinical Social Worker

Diagnostic Imaging Technician

Diagnostic Imaging Tech – Computed Tomography

Diagnostic Imaging Tech – Mammography

Diagnostic Imaging Technician – Ultrasound

Exercise Physiologist

Family Nurse Practitioner

Family Practice Physician

Flight Medicine Provider

Health and Fitness Specialist

Licensed Practical Nurse-Outpatient

Licensed Vocational Nurse -Outpatient

Medical Appointment Clerk

Medical Laboratory Technician

Medical Logistics Supply Technician

Medical Office Clerk

Medical Records Technician Mental Health Technician

Optometrist

Optometry Technician

Orthopedic Technician

Pediatrician

Pediatric Nurse Practitioner

Pharmacist – Clinical

Pharmacist – Registered

Pharmacist Technician

Phlebotomist

Physical Therapist

Physical Therapy Technician-Assistant

Physician Assistant

Physician Assistant - Orthopedic

Psychiatric Nurse

Psychiatrist

Psychologist

Radiologist

Referral Clerk

Registered Dietician

Registered Nurse – Case Manager

Social Worker – Special Needs Coordinator

Utilization Management Nurse

Women’s Health Nurse Practitioner

Other Medical Positions Not Listed

Total FTE(s): ________________

ADDITIONAL COMMENTS: