ATTCH 4 - Past Performance Questionaire.pdf

Attachment 4 – Past Performance Questionnaire

Travis AFB is in the process of soliciting offers from companies capable of providing:

Urinalysis Lab Analyzer

In order for 60th Contracting Squadron to conduct its evaluation, we request that you complete the questionnaire below and email a PDF file to: juliet.diggs.1@us.af.mil, Contract Specialist, at 60 CONS, Travis AFB. The due date for completed questionnaires is: 31 May at 12:00 PM Pacific Standard Time. Your completed questionnaire will become part of the official source selection records. To be considered, the Past Performance Questionnaire shall be returned to the Contract Specialist in its entirety and by the due date and time specified above.

To confirm receipt of your completed/submitted questionnaires, please contact:

Contract Specialist: Juliet Diggs by email at juliet.diggs.1@us.af.mil, Tel: 707-424-7772.

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

A. OFFEROR’s REFERENCE INFORMATION:

Contract Name and/or Number (Include task order number(s) if applicable:

Company (Include task order number(s) if applicable:

Address:

POC of Contact (POC):

Title of POC:

Telephone Number:

Email:

Contractor performed as: Prime Contractor Sub-Contractor

B. RESPONDENT INFORMATION: Please complete

Contracting Activity/Customer:

Address:

Telephone Number:

Email Address:

Point of Contract (POC) Title of POC:

C. CONTRACT INFORMATION: Please Complete.

Contract Name and/or Number

Task Order Number:

Type of Contract:

Performance Period (Base plus any options)

Annual Contract Value:

Total Contract Dollar Value: (base plus options)

Number of FTEs

Contract Description:

Contractor performed as: Prime Contractor:

Sub-Contractor:

If subContractor: What percentage was performed by the evaluated Contractor

A. PERFORMANCE INFORMATION: Choose the appropriate number on the scale (1, 2, 3, 4, and

5) that most accurately describes the Contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 4 or 5.

1 2 3 4 5

Substantial Confidence

Satisfactory Confidence

Neutral Confidence

Limited Confidence

No Confidence

Based on the Based on the No recent/relevant Based on the Based on the offeror’s offeror’s performance record offeror’s offeror’s recent/relevant recent/relevant is available or the recent/relevant recent/relevant performance performance offeror’s performance performance record, the record, the performance record record, the record, the Government has a Government has a is so sparse that no Government has a Government has no high expectation reasonable meaningful low expectation expectation that the that the offeror will expectation that the confidence that the offeror will offeror will be able successfully offeror will assessment rating successfully to perform the successfully can be reasonably perform the successfully required effort. perform the assigned. required effort. perform the required effort. The offeror may required effort.

not be evaluated favorably or unfavorably on the factor of past performance.

Place an “X” in the appropriate column using the definitions matrix above.

THE CONTRACTOR 1 2 3 4 5

1 The Contractor provided quality service that adhered to contract requirements.

2 The Contractor consistently responded to problems and took appropriate action to correct performance.

3 Did the contract involved hard to fill positions (specialty positions) or positions in high cost of living areas? If so, did Contractor successfully recruit and retain qualified contracted medical personnel with minimal disruption?

4 Contractor corrected deficiencies in timely manner and pursuant to their contract requirements.

5 Contractor demonstrated an overall effective and quality management effort.

6 Contractor cooperated with the Government in providing flexible, proactive and effective solutions to critical contract issues.

7 Contractor demonstrated ability to plan for and provide replacement candidates during the life of the contract to include preplanned absences, unplanned illnesses, or an extended leave of absence.

THE CONTRACTOR 1 2 3 4 5

8 Contractor consistently demonstrated an ability to quickly recruit and retain qualified medical contract personnel in accordance with the contract requirements to avoid disruption of services and/or work schedule.

9 Credentialing packages (to include current and complete information) were presented in timely to the applicable Credentialing office?

10 How would you rate the Contractor’s overall performance

Is the Contractor rated in CPARS?

Yes No

12 Was the Contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.”

13 Would you award another contract to this Contractor? If not, explain in “remarks.”

Additional Remarks

Print Name & Title

Date