Attch 4_PPQ RMC.pdf

Attachment 4, Past Performance Questionnaire (PPQ)

FA561322R0005

Past Performance Questionnaire (PPQ)

The purpose of this requirement is to provide non-personal services as Referral Management Center (RMC) in support of the 86th Medical Group (86 MDG). The Contractor shall provide all management, supervision and personnel to obtain medical consultation and administrative support for the Medical Treatment Facility (MTF) staff and beneficiaries.

A. GENERAL INFORMATION: Please correct any information below known to be inaccurate:

Contractor’s Name: ____________________ Address:

Telephone Number: ____________________

Email Address: ____________________

Point of Contact: ____________________

Project Title or Brief Description of Work*:

Contract Number*: Contract Amount:

Contract Period or Dates of Performance*:

Contractor performed as the Prime Contractor: YES NO

To be completed by the respondent and returned directly to the contracting office.

* Note: If offeror holds or has held other contracts with your agency/organization in the last 3 years, please complete separate evaluation forms for those contracts as well.

B. RATER INFORMATION:

Name of Rater: __________________________________________

Title: __________________________________________

Address: __________________________________________

Phone Number: __________________________________________

Email Address: __________________________________________

C. RETURN COMPLETED SURVEY FORM NOT LATER THAN 29 MARCH 2022 TO:

Lena Kronen/Contract Specialist TSgt Kelly S. McGrath/Contracting Officer

700 CONS/PKA 700 CONS/PKA

lena.kronen.de@us.af.mil kelly.mcgrath.1@us.af.mil

CONTRACTOR’S NAME: CONTRACT NUMBER:

D. PERFORMANCE INFORMATION: Choose the appropriate letter on the scale (E, G, S, M, U, and N) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF M or U.

E G S M U N

Exceptional Good Satisfactory Marginal Unsatisfactory Neutral

Performance meets contractual requirements and exceeds many to your organization’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.

Performance meets contractual requirements and exceeds some to your organization’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.

Performance meets contractual requirements.

The contractual performance of the element or sub-element being assessed contains some minor problems for which corrective actions taken by the contractor were satisfactory.

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 or the contractor’s proposed actions appear only marginally effective or were not fully implemented.

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 being assessed contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Performance was not observed or not applicable to the current effort being reported against.

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

The contractor: E G S M U N

1. Did contractor assign personnel with required skills to accomplish the work?

2. Did contractor personnel provide timely and accurate information/performance to all administration support tasks?

3. Demonstrated ability to hire, maintain, and/or replace, if necessary, qualified personnel during the contract period.

4. Interfaced and cooperated with government quality assurance personnel during contract performance.

5. Provided adequately trained and certified personnel.

Did contractor personnel create/provide proper and accurate schedules/templates in patient appointment computer system (if applicable)?

6. Provided effective quality control and/or inspection procedures to meet contract requirements.

7. Provided timely resolution of contract discrepancies pursuant to their quality control procedures and established procedures to prevent recurrence of discrepancy.

8. Provided adequate project supervision.

9. Identified problems as they occurred and/or suggested alternative approaches to problem resolutions.

10. Displayed initiative to solve problems and follow-up to ensure desired results were achieved.

11. Provided timely and courteous services.

12. Contractor personnel were professional in appearance.

13. Contractor personnel were professional in their interactions with patients.

14. Complied with environmental requirements, if applicable.

15. Was responsive to contract changes (if applicable).

16. Contractor adequately coped with any sudden surge in requirements (if applicable).

17. Did contractor consistently respond within the required time frames?

18. How would you rate the vendor's overall performance?

19. For US Government contracts only: Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, please explain outcome in the “Remarks” section.

YES / NO

20. For US Government contracts only: Is the contractor rated in CPARS? YES / NO

21. Would you award another contract to this contractor? If not, please explain why in the “Remarks” section.

YES / NO

REMARKS/COMMENTS: