E.4 - Past Performance Questionnaire.docx

Exhibit E.4 Past Performance Questionnaire 75FCMC26R0041

PERFORMANCE QUESTIONNAIRE

Sample Cover Letter

[COMPANY LETTERHEAD (Prime or subcontractor)]

Reference Name, Address and Contact information Date

SUBJECT: RFP- 75FCMC26R0041 - Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC)

Dear _________________:

We are currently responding to the Centers for Medicare & Medicaid Services (CMS) Request for Proposal number RFP- 75FCMC26R0041 (as a subcontractor to______ (If applicable)). The purpose of this contract is to perform ____________________________________________ (to be filled in by Offeror).

There is an increased emphasis on past performance in the federal source selection process. The CMS is requesting that customers and clients of Offerors provide the information as described within the attached questionnaire and return it to them for evaluation. We have identified you as one of our references and respectfully request that you complete and sign the attached questionnaire and then return it to CMS.

Questionnaires are due to CMS no later than ____________ (to be filled in by Offeror); however, we would appreciate an earlier response if at all possible.

We sincerely appreciate your cooperation in this matter.

Sincerely, Reference Name Title

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop B3-30-03 Baltimore, Maryland 21244-1850 Office of Acquisition and Grants Management

To Whom It May Concern:

The Centers for Medicare & Medicaid Services (CMS) very much appreciates your time and thoughtfulness in completing the attached questionnaire. The information obtained from this questionnaire will be utilized to evaluate the past performance of Offerors/Contractors who wish to be awarded a contract with CMS.

CMS may engage in exchanges with offerors regarding past performance information submitted to CMS in connection with the subject solicitation. If CMS engages in such exchanges, CMS may share information disclosed in this survey with the Offeror to whom it pertains, as permitted or required by the FAR. Otherwise, CMS will only share information from this survey outside the agency pursuant to a protective order or as otherwise required by law

The questionnaire is arranged by quality of service/performance, cost control, timeliness and management. Each area consists of one or more basic questions relating to these aspects of performance with regard to the Offeror/Contractor with which you worked. Please complete the questionnaire as indicated on the form.

Finally, please sign your name and identify your position during your association with the referenced Offeror/Contractor. Once completed, please submit the questionnaire to:

Thank you for taking the time to complete the questionnaire.

Sincerely,

PAST PERFORMANCE QUESTIONNAIRE

CMS Solicitation No. 75FCMC26R0041

(Company Being Evaluated) (Offeror)

Title/ Name of Contract (being Evaluated):__________________________________________________

Brief Description of Work: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Contract Type:________________________________________________________________________ Total Contract Value:___________________________________________________________________ Performance Period:____________________________________________________________________

Please complete the following questionnaire about the Offeror/Contractor and indicate your responses in the blocks or columns, as appropriate. Numerical ratings are as indicated in the Rating Scale below. Other Ratings are as indicated in each block.

Rating Scale:

We request that you justify each of your ratings with a comment. Please be as specific in your comment as possible, especially in situations that warrant very high or very low ratings. Use extra pages as necessary or expand the form electronically as needed.

Q1. Quality: Did the Offeror demonstrate the execution of quality efforts resulted in effective performance outcomes for work activities?

Q2. Cost Control: Did the Offeror demonstrate the ability to ensure costs were within budget?

Q3. Schedule: Did the Offeror demonstrate the ability to consistently meet project milestones and deliverables on time?

Q4. Management: Did the Offeror demonstrate a past track record of notifying its contractors/customers of problems, remaining flexible and reliable, and being responsive to contract requirements and recommending solutions? How well did the Offeror match the qualifications of the key position, as described in the contract, with the person that filled the key position? Did the Offeror support key personnel so they were able to work effectively?

Agency/Company COMPLETING Questionnaire

Agency/Company Name: ___________________________

Address: ___________________________

Signature of Individual Completing the Questionnaire: ____________________________________ Date

Name: ___________________________ Telephone No.: ________________________

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