ATTACHMENT C - Past Performance Questionnaire.docx
DOCX document 30 KB Posted
- Attached to
- Physician Services
- Solicitation number
- 75H71026Q00228
About this file
This is a Past Performance Reference Questionnaire template for a non-personal physician services contract at Tohatchi Health Center in Tohatchi, New Mexico, solicitation number 75H71026Q00228, issued by the Indian Health Service under the Department of Health and Human Services. The 100% Indian-owned Small Business Economic Enterprise (ISBEE) set-aside solicitation requires offerors to submit a minimum of three (3) and a maximum of five (5) completed questionnaires from past performance references, with all questionnaires due directly to the Contracting Officer, Misty Billy (Misty.Billy@ihs.gov), no later than 10:00 am MDT on August 31, 2026. Questionnaires must be submitted directly by references and not on behalf of references by the offeror.
The questionnaire evaluates contractor performance across ten key criteria using a five-point rating scale (Exceptional, Very Good, Satisfactory, Marginal, Unsatisfactory, or Not Applicable). Critical evaluation areas include continuity of physician coverage for all required shifts, credential compliance and maintenance of current licensure, vacancy response timeliness, clinical quality of care, medical record documentation compliance, credentialing pre-placement timeliness, performance in rural and tribal healthcare settings, communication and responsiveness to government representatives, professionalism and conduct of placed physicians, and overall contractor satisfaction. Each reference must include supporting narratives for all ratings and provide a recommendation regarding contractor suitability for similar physician staffing contracts in rural, remote, tribal, or federally operated healthcare settings.
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PAST PERFORMANCE REFERENCE QUESTIONNAIRE
Non-Personal Physician Services | Tohatchi Health Center | Navajo Area Indian Health Service | Tohatchi, New Mexico Solicitation No.: [Insert] | Issued: [Insert Date] **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
| Rating |
| Symbol |
| Definition |
| Exceptional |
| E |
| Performance met contractual requirements and exceeded many to the Government's benefit. Few minor problems occurred and corrective actions were highly effective. Multiple significant events benefited the Government. No significant weaknesses identified. |
| Very Good |
| VG |
| Performance met contractual requirements and exceeded some to the Government's benefit. Some minor problems occurred and corrective actions were effective. At least one significant event benefited the Government. No significant weaknesses identified. |
| Satisfactory |
| S |
| Performance met contractual requirements. Minor problems occurred and corrective actions were satisfactory. No significant weaknesses identified. Contractors will not be rated below Satisfactory solely for not exceeding requirements. |
| Marginal |
| M |
| Performance did not meet some contractual requirements. Serious problems were identified for which corrective actions were only marginally effective or not fully implemented. Supported by reference to a deficiency notice or corrective action document. |
| Unsatisfactory |
| U |
| Performance did not meet most contractual requirements and recovery was not timely. Corrective actions were ineffective. Supported by reference to deficiency notices or corrective action documents. |
| Not Applicable |
| N/A |
| The question does not apply to this contract. |
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
| Rater's Role in Relation to the Contract |
| ☐ Contracting Officer ☐ COR ☐ Program/Project Manager ☐ Major End User ☐ Other: _______________ |
Dates of Your Involvement with This Contract
SECTION I — Contractor Performance
Important: Please evaluate the contractor's performance in providing physician staffing and clinical support services, including both the quality of physician services delivered and the contractor's ability to maintain continuous, reliable coverage.
| # |
| Question |
| Rating |
(Bold/underline selection) Supporting Narrative (Required for all ratings)
| 1 |
| Continuity of Coverage. How would you rate the contractor's ability to provide continuous, uninterrupted physician coverage for all required shifts/schedules throughout the contract period? |
Please describe any periods of coverage gaps and how the contractor responded.
E VG S M U N/A
| 2 |
| Credential Compliance. How would you rate the contractor's ability to ensure that placed physicians maintained current, valid, and unrestricted licensure and required certifications throughout the contract period, with no lapses resulting in uncredentialed personnel performing services? |
Please describe any instances of credential lapses and how they were resolved.
E VG S M U N/A
| 3 |
| Vacancy Response and Contingency Coverage. How would you rate the contractor's responsiveness when a placed physician became unexpectedly unavailable — including timeliness of notification and speed of confirmed replacement? |
Please describe typical response time and any instances where coverage was not restored within an acceptable timeframe.
E VG S M U N/A
| 4 |
| Clinical Quality of Care. How would you rate the quality of clinical care delivered by physicians placed under this contract, including diagnosis, treatment, and patient management consistent with applicable standards of care? |
Please describe any substantiated patient safety, quality, or standard-of-care concerns and how they were addressed.
E VG S M U N/A
| 5 |
| Medical Record and Documentation Compliance. How would you rate the contractor's/physicians' ability to complete all required patient medical records, chart entries, and clinical documentation in a timely and accurate manner? |
Please describe any instances of incomplete or deficient documentation and how they were addressed.
E VG S M U N/A
| 6 |
| Credentialing and Pre-Placement Timeliness. How would you rate the contractor's ability to complete credentialing, licensing verification, and other pre-placement requirements for physicians in a timely manner that supported the required start date and continuity of coverage? |
E VG S M U N/A
| 7 |
| Performance in Rural, Remote, Tribal, or Federally Operated Healthcare Settings. How would you rate the contractor's/physicians' effectiveness in operating within a rural, remote, Tribal, or federally operated healthcare environment — including cultural sensitivity, understanding of unique operational constraints, and ability to sustain coverage in difficult-to-staff locations? |
Please describe the nature of the setting and any specific challenges encountered or strengths demonstrated.
E VG S M U N/A
| 8 |
| Communication and Responsiveness to the Government. How would you rate the contractor's responsiveness to the Contracting Officer and COR — including timeliness of required notifications, accuracy of required reports, and willingness to address performance concerns proactively? |
Please describe any instances of communication failures or unresolved concerns.
E VG S M U N/A
| 9 |
| Professionalism and Conduct. How would you rate the professionalism and conduct of physicians placed under this contract, including adherence to applicable codes of conduct and facility policies? |
Please describe any substantiated conduct concerns and how they were resolved.
E VG S M U N/A
| 10 |
| Overall Performance. How would you rate your overall satisfaction with the contractor's performance on this contract? |
| E VG S M U N/A |
| 11 |
| Recommendation. Would you recommend this contractor for a similar physician staffing contract in a rural, remote, Tribal, or federally operated healthcare setting? |
☐ 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
By signing below, I certify that the information provided in this questionnaire is accurate and reflects my direct knowledge of the contractor's performance on the referenced contract.
Signature: _________________________ 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 — 75H71026Q00228 — [Insert Offeror Company Name]
Due Date: Please return the completed questionnaire no later than 10:00 am MDT on August 31, 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]
File details come from the government source that posted it. Updated .