Section_J_Attachment_13_-_Past_Perf_Questionnaire_Template_123013FD.doc
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- Solicitation Notice for Workers' Compensation Medical Bill Processing (WCMBP) Federal contract opportunity
- Solicitation number
- DOL141RP21903
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United States Department of Labor
(DOL)
Workers’ Compensation Medical Bill Process (WCMBP)
Attachment 13 –
Past Performance Questionnaire Template December 30, 2013 Office of Workers’ Compensation Programs (OWCP) Unique Project Identifier:
| I |
| Contract Identification |
| A. |
| Contractor Name: |
| B. |
| Contract Number: |
| C. |
| Contract Type: |
Competitive?
Yes
No
Follow-on?
Yes
No
| D. |
| Original Estimate: |
Initial Cost (or Fixed Price)
Initial Fee
Total Initial Cost & Fee
| E. |
| Current Estimate: |
Current Cost (or Fixed Price)
Current Fee
Total Current Cost & Fee
| F. |
| Initial Period of Performance: |
From
To:
| G. |
| Current Period of Performance |
From
To:
| H. |
| Project Description and/or Service Provided: |
| II |
| Agency Identification: |
| A. |
| Name |
| B. |
| Address |
| C. |
| Telephone |
| III |
| Performance History |
| A. |
| Describe the quality of supplies delivered or services rendered in terms of compliance with the Statement of Work, Performance Work Statement, and Specifications |
| B. |
| Was the work performed within the negotiated period of performance and/or delivered according to the negotiated delivery schedule? |
Yes
No
If No, please explain:
Was this considered excusable?
Yes
No
| C. |
| Was the work completed within the negotiated price? |
Yes
No
If No, please identify the amount of the price increase, describe the reasons for the price growth, and address the Contractor’s ability to forecast and control price.
| D. |
| Did the Contractor reasonably comply with the other terms and conditions of the contract? |
Yes
No
If No, please explain:
| E. |
| How would you rate the Contractor’s willingness in cooperating with and assisting the Government in resolving issues and problems? |
Exceptional
Good
Average / No Record
Marginal
Unacceptable
If your rating is Marginal or Unacceptable, please explain:
| F. |
| How would you rate the Contractor’s status reporting? Factor in accuracy, completeness and timeliness. |
Exceptional
Good
Average / No Record
Marginal
Unacceptable
If your rating is Marginal or Unacceptable, please explain:
| G. |
| How would you rate the Contractor’s initiative in committing to the contract adequate resources in a timely fashion to satisfy the requirements and to successfully resolve problems? |
Exceptional
Good
Average / No Record
Marginal
Unacceptable
If your rating is Marginal or Unacceptable, please explain:
| H. |
| How would you rate the Contractor’s submittal of change orders and other required proposals in a timely manner? |
Exceptional
Good
Average / No Record
Marginal
Unacceptable
If your rating is Marginal or Unacceptable, please explain:
| I. |
| How would you rate the Contractor’s ability to provide qualified and experienced personnel, with all necessary background investigations, as required by the contract? |
Exceptional
Good
Average / No Record
Marginal
Unacceptable
If your rating is Marginal or Unacceptable, please explain:
| J. |
| How would you rate the overall performance of the Contractor? |
Exceptional?
Good?
Average / No Record?
Marginal?
Unacceptable?
If your rating is Marginal or Unacceptable, please explain:
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