ATTACHMENT C - Past Performance Questionnaire.docx

PAST PERFORMANCE REFERENCE QUESTIONNAIRE

Non-Personal Pharmacist Services | Gallup Indian Medical Center | Navajo Area Indian Health Service | Gallup, New Mexico

Solicitation No.: 75H71026Q00225 | Issued: 8/5/2026

Instructions to Offeror: Complete the shaded Offeror Header Block below and provide this questionnaire to each of your past performance references. Instruct each reference to complete Sections I through III and return the completed questionnaire directly to the Contracting Officer at the address in Section IV. Do not submit completed questionnaires on behalf of your references. Questionnaires submitted by the offeror will not be accepted. A minimum of three (3) and a maximum of five (5) completed questionnaires must be received directly from references by the quote due date identified in the solicitation.

OFFEROR HEADER BLOCK — To Be Completed by the Offeror

Offeror (Company) Name

Contract Number Being Referenced

Contract Title / Description

Period of Performance

Place of Performance (City, State; Facility Type)

Contracting Agency or Customer

Brief Description of Services Performed

RATING DEFINITIONS

Note: When completing this questionnaire electronically, do not use colored font to indicate your rating selection. Bold, underline, or increase the font size of your selected rating in black text.

REFERENCE INFORMATION — To Be Completed by the Reference

Rater Name

Rater Title

Rater Organization

Rater Telephone

Rater Email Address

Dates of Your Involvement with This Contract

SECTION I — Contractor Organizational Performance

Important: All questions assess the organizational performance of the contractor as a staffing firm — not the clinical performance of individual pharmacists or health professionals placed under the contract. Please evaluate the contractor's performance as an organization in fulfilling its staffing, scheduling, credentialing, and administrative obligations.

(Bold/underline selection) Supporting Narrative (Required for all ratings)

Please state the approximate fill rate achieved as a percentage of scheduled shifts covered, and describe any periods of significant coverage gaps and how the contractor responded.

E VG S M U N/A

Please describe any instances of credential lapses, how quickly the contractor identified and resolved them, and whether any resulted in uncredentialed personnel performing services.

E VG S M U N/A

Please describe the contractor's typical response time to unplanned vacancies and any instances where coverage was not restored within an acceptable timeframe.

E VG S M U N/A

Please describe any instances of late, incomplete, or inaccurate roster submissions and how the contractor resolved them.

E VG S M U N/A

Please describe any instances of incomplete records or documentation deficiencies and how the contractor addressed them.

E VG S M U N/A

Please describe any instances where personnel departed without completing required closeout procedures and how the contractor responded.

E VG S M U N/A

Please describe the nature of the setting and any specific challenges the contractor encountered or demonstrated particular strength in addressing.

E VG S M U N/A

Please describe any instances of communication failures, delayed notifications, or unresolved performance concerns, and how contractor management responded.

E VG S M U N/A

Please describe any instances where the contractor's internal QC program identified and resolved a performance issue before it was escalated to the Government.

E VG S M U N/A

☐ Yes, without reservation ☐ Yes, with minor reservations (please explain below) ☐ No (please explain below) Supporting Narrative:

SECTION II — Additional Supporting Narrative

(Include the question number to which the narrative applies. Additional pages may be attached.)

SECTION III — Certification and Signature of Rater

Date:

Printed Name / Title:

SECTION IV — Return Instructions

⚠ This questionnaire must be submitted directly by the reference to the Contracting Officer. Do not return this questionnaire to the offeror.

Please complete this questionnaire and submit it via email directly to:

Contracting Officer: Misty Billy Email: Misty.Billy@ihs.gov Subject Line: PPQ —75H71026Q00225 — [Insert Offeror Company Name]

Due Date: Please return the completed questionnaire no later than 10:00 AM MDT on August 25, 2026.

Questionnaires received after the due date may not be considered. The Government will not follow up with references to obtain questionnaires not received by the due date.

SECTION V — Questions

For questions regarding this questionnaire, please contact:

Name: [Insert] Title: [Insert] Telephone: [Insert] Email: [Insert]