ESBD_531743_1782487415588_ATTACHMENT G.4 References & Past Performance.pdf
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- Solicitation number
- TMD26-SEC-0039103
- Issued by
- Texas
About this file
This is a References and Past Project Performance Sheet attachment for solicitation RFQ TMD-26-SEC-0039103, issued by the Texas Department (TMD) for Psychologist or Psychiatry Services utilizing the MMPI assessment tool. Respondents are required to submit a minimum of three (3) references from state, federal, and/or local governmental entities documenting their ability to perform similar services within the past five (5) years. Each reference entry requires detailed project information including project description, contact name and organization, contract amounts (both original and final), service descriptions, and clarification of whether the respondent served as the primary contractor or subcontractor. The form also requests identification of project start dates, projected completion dates, and actual completion dates for each reference project.
The submission form requires respondents to disclose any sanctions, liquidated damages, or other monetary remedies assessed under existing or past contracts during the preceding five years, as well as any threatened, pending, or resolved disciplinary actions for substandard work or unethical practices. Respondents must also report any orders, judgments, or decrees from federal or state authorities that would bar or limit their ability to conduct business. Additionally, respondents must disclose involvement in civil or criminal litigation, compromise agreements, settlement agreements, or consent decrees related to contract performance or the services being solicited, provided such disclosure does not violate confidentiality provisions. The form requires explicit disclosure of any project terminations, contract defaults, or contracts terminated for convenience within the past five years, with full details including the other party's contact information.
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ATTACHMENT G.4 REFERENCES AND PAST PROJECT
PERFORMANCE SHEET
Must Be Completed and Returned with Response.
Solicitation RFQ TMD-26-SEC-0039103 Psychiatry Services for MMPI-
Texas Respondent must provide a minimum of three (3) references who are willing and able to provide documentation about Respondent’s ability to perform similar requested services. These references must relate to similar contracts or projects performed as described in the solicitation within the last five (5) years and be from state, federal, and/or local governmental entities. Do Not include TMD as a reference.
#1-Project Description:
Contact Name:
Name of the organization to which the service was provided:
Reason for contract termination/expiration, if contract is no longer in effect:
Contact Number: Contact E-Mail Address:
Original Contract Amount: Final Contract Amount:
Types of services directly provided by the Respondent and whether the Respondent was the contractor or Subcontractor:
#2-Project Description:
Contact Name:
Name of the organization to which the service was provided:
Reason for contract termination/expiration, if contract is no longer in effect:
Original Contract Amount: Final Contract Amount:
Types of services directly provided by the Respondent and whether the Respondent was the contractor or Subcontractor:
#3-Project Description:
Contact Name:
Name of the organization to which the service was provided:
Reason for contract termination/expiration, if contract is no longer in effect:
Contact Number: Contact E-Mail Address:
Original Contract Amount: Final Contract Amount:
Types of services directly provided by the Respondent and whether the Respondent was the contractor or Subcontractor:
Start Date: Projected Completion Date: Actual Completion Date:
The Respondent has been assessed any Sanctions, including liquidated damages or other such monetary remedies, under any existing or past contracts during the last five (5) years, and, if so, note the reason for and the amount assessed or paid for each incident.
The Respondent was the subject of (i) any threatened, pending, or resolved disciplinary action for substandard work and/or unethical practices; or (ii) any order, judgment or decree of any federal or state authority barring, suspending or otherwise limiting the right of the Respondent to engage in any business, practice, or activity, during the last five (5) years.
The Respondent has been involved in any civil or criminal litigation and/or entered into any compromise agreement, settlement agreement, or resulting consent decree or judgements, if applicable, related to contract performance, the goods and/or services sought by this Solicitation, or that a reasonable person knowledgeable of the applicable industry would consider relevant to the work under the Contract. Respondents are not required to violate any confidentiality provision but must provide information not prohibited from disclosure.
Indicate if your company has had a project terminated, stopped in the middle, contract terminated for default or convenience within the past five
(5) years. Yes or No, If yes, provide explanation full details including the others party’s name, address, and telephone number.
FORM 3 – REFERENCES AND PAST PROJECT PERFORMANCE SHEET
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