WCMBP_Section_J_Attachment_13_-_Past_Performance_Questionaire_Template_AMD3.pdf

United States Department of Labor

(DOL)

Workers’ Compensation Medical Bill Process (WCMBP)

Attachment 13 – Past Performance Questionnaire

Template

May 20, 2014

Office of Workers’ Compensation Programs (OWCP)

SERVICES, INFORMATION TECHNOLOGY, AND OPERATIONS SUPPORT

CPAR FORM

FOR OFFICIAL USE ONLY (When Filled In)

FOR OFFICIAL USE ONLY (When Filled In)

CONTRACTOR PERFORMANCE ASSESSMENT REPORT (CPAR ) - SERVICES

(Source Selection Sensitive Information) (See FAR 3.104)

1. NAME/ADDRESS OF CONTRACTOR (Division)

CAGE CODE DUNS+4 NUMBER

FSC OR SERVICE CODE SIC CODE

2. INITIAL INTERMEDIATE FINAL REPORT ADDENDUM

3. PERIOD OF PERFORMANCE BEING ASSESSED

From To

4a. CONTRACT AND ORDER NUMBER 4b. CONTRACT PERIOD

5. CONTRACTING OFFICE (ORGANIZATION AND CODE)

6. LOCATION OF CONTRACT PERFORMANCE (If not in item 1) 7a. CONTRACTING OFFICER 7b. PHONE NUMBER

8. CONTRACT AWARD DATE 9. CONTRACT COMPLETION DATE

10. PROGRAM OFFICE

11. AWARDED VALUE 12. CURRENT CONTRACT DOLLAR VALUE

13. COMPETITIVE NON-COMPETITIVE

14. CONTRACT TYPE

FFP FPI FPR CPFF CPIF CPAF MIXED OTHER

15. KEY SUBCONTRACTORS AND DESCRIPTION OF EFFORT PERFORMED

16. PROGRAM TITLE AND PHASE OF ACQUISITION (If applicable)

17. CONTRACT EFFORT DESCRIPTION (Highlight key components, technologies and requirements; key milestone events and major modifications to contract during this period.)

CURRENT RATING

18. EVALUATE THE FOLLOWING AREAS Unsatisfactory Marginal Satisfactory Very Good Exceptional N/A

Quality of Product or Service

Schedule

Cost Control

Business Relations

Management of Key Personnel

Utilization of Small Business

Other Areas: See Block 19 and Additional Information Block

FOR OFFICIAL USE ONLY (When Filled In)

FOR OFFICIAL USE ONLY (When Filled In)

19. ASSESSING OFFICIAL (PROGRAM MANAGER OR EQUIVALENT INDIVIDUAL RESPONSIBLE FOR PROGRAM, PROJECT, OR TASK/JOB ORDER EXECUTION) NARRATIVE

20. NAME AND TITLE OF ASSESSING OFFICIAL ORGANIZATION & CODE PHONE NUMBER

SIGNATURE DATE

21. CONTRACTOR COMMENTS (Optional)

22. NAME AND TITLE OF CONTRACTOR REPRESENTATIVE PHONE NUMBER

SIGNATURE DATE

23. REVIEW BY REVIEWING OFFICIAL (Comments Optional)

24. NAME AND TITLE OF REVIEWING OFFICIAL ORGANIZATION & CODE PHONE NUMBER

SIGNATURE DATE

FOR OFFICIAL USE ONLY (When Filled In)

FOR OFFICIAL USE ONLY (When Filled In)

ADDITIONAL INFORMATION (optional) 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?

C. Was the work completed within the negotiated price?

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?

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.

Good Average / No Record Marginal

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?

Good Average / No Record Marginal

H. How would you rate the Contractor’s submittal of change orders and other required proposals in a timely manner?

Good Average / No Record Marginal

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?

Good Average / No Record Marginal

J. How would you rate the overall performance of the Contractor?

Exceptional?

Good?

Average / No Record?

Marginal?

Unacceptable?