Attachment_A_DPHHS-RFP-2024-0511KH_PATH_Client_Reference_Form.docx
DOCX document 60 KB Posted
- Solicitation number
- DPHHS-RFP-2024-0511KH
- Issued by
- Montana
About this file
This document is a Reference Check Form template for the Projects for Assistance in Transition from Homelessness (PATH) program, intended to be used by the Montana Department of Public Health and Human Services. The form is designed for collecting vendor performance feedback through a structured reference check process, with spaces for recording contact information, service details, and evaluative ratings across multiple performance dimensions such as timeliness, personnel skills, problem resolution, and overall customer service.
The reference check form utilizes a standardized rating scale from 0-3, with categories ranging from "Unsatisfactory" to "Exceeds Expectations," allowing reference contacts to provide nuanced feedback about a vendor's performance. The form includes sections for documenting the reference's assessment of the vendor's contract value, budget adherence, service delivery, and professional conduct, with an option for additional comments. There is also a section to document unsuccessful reference check attempts, which provides alternative documentation if a reference cannot be reached or declines to participate in the evaluation process.
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Text version
REFERENCE CHECK FORM (SAMPLE)
For: [Title of Solicitation]
Respondent Name: Click or tap here to enter text.
Company to be contacted as a Reference: Click or tap here to enter text.
Name and Title of Designated Reference: Click or tap here to enter text.
Contact Number for Designated Reference: Click or tap here to enter text.
Point of Contact Information for Individual Responding to Reference Check, if different than Point of Contact Designated in the Response: Click or tap here to enter text.
Introduction Hello, my name is [caller’s name] with [agency name]. We are currently evaluating vendor proposals for [solicitation title] and checking vendor references. Your name and number were provided to us as a reference for [vendor name]. Do you have a few minutes to answer some questions?
Questions
1. Has the vendor provided [description of products/services] to your organization in the past 3 years?
☐ Yes ☐ No
2. How long has the vendor provided [description of products/services] to your organization?
3. What is the approximate annual value of the vendor’s contract? Click or tap here to enter text.
4. Did the vendor stay within budget?
☐Yes ☐No On a rating scale of 0 to 3 – where (0) Unsatisfactory, (1) Marginally Satisfactory, (2) Satisfactory, (3) Exceeds Expectations, and (N/A) Not Applicable – please provide answers to the following questions:
1. How satisfied was your organization with the timeliness of the vendor’s delivery of products or performance of services under the contract?
1 2 3 NA Declined to Respond
2. How satisfied was your organization with the skill, knowledge, cooperativeness, and professional manner of the personnel assigned by the vendor?
1 2 3 NA Declined to Respond
3. How satisfied was your organization with the vendor’s ability to resolve problems?
1 2 3 NA Declined to Respond
4. How satisfied was your organization with the vendor’s customer service?
1 2 3 NA Declined to Respond
5. Overall, how satisfied was your organization with the vendor’s performance?
1 2 3 NA Declined to Respond
6. Do you have any comments? Click or tap here to enter text.
Reference check activities were unsuccessful for the following reason(s):
Designated point of contact declined to answer any questions.
Designated point of contact information provided in response was incorrect.
Designated point of contact was determined to be “unavailable” after Click to enter number unsuccessful attempts on the following dates and times:
Click to enter dates and times
Other: Click or tap here to enter text.
Reference Check Conducted By: Click or tap here to enter text.
Date & Time: Click or tap here to enter text.
Revised April 2020 image1.emf image2.png
File details come from the government source that posted it. Updated .