Exhibit D - DRAFT Past Performance Questionnaire.docx
DOCX document 40 KB Posted
- Attached to
- Clinical Reference Laboratory Testing Services
- Solicitation number
- HT001526RE001
- Issued by
-
Defense Health Agency
About this file
This is a Past Performance Questionnaire template designed for use in the Clinical Reference Laboratory Testing Services (CRLTS) solicitation HT001526RE001 issued by the Defense Health Agency (DHA). The questionnaire must be completed and signed by past performance references and submitted via email to the DHA Healthcare Contracting Division-Central points of contact. The template collects comprehensive information about the contractor's reference, the specific contract being evaluated, and contract performance details including annual contract value, geographic scope, and approximate number of laboratory tests performed annually, with specific notation of whether STAT courier services were provided and the contractor's role (prime, subcontractor, teaming partner, or joint venture).
The questionnaire employs a standardized five-point assessment scale (Exceptional, Very Good, Satisfactory, Marginal, Unsatisfactory, and Not Applicable) to evaluate contractor performance across five key categories: Quality of Service, Cost Control, Timeliness/Schedule, Business Relationships, and Key Personnel. Each category contains specific evaluation criteria with checkboxes and space for narrative explanation when performance exceeds or falls short of satisfactory standards. The form concludes with a summary section requesting the evaluator's recommendation on whether to award the firm another contract, notification of any default or cause terminations, and space for additional comments, with signature block and contact information for the evaluator.
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EXHIBIT E - PAST PERFORMANCE QUESTIONNAIRE
This questionnaire must be filled out and signed by the past performance reference. The reference will submit all completed and signed questionnaires via email to tamara.k.fenwick.civ@health.mil and melissa.l.hearst.ctr.@health.mil
The DHA Healthcare Contracting Division-Central is conducting a Single Award ID/IQ competition for Solicitation Number, HT0015-26-R-E001. This solicitation is for qualified Reference Laboratory Testing Services to support the DHA Enterprise CONUS and OCONUS: over 6,000 required laboratory tests to approximately 200 Military Treatment Facilities.
RESPONDENT INFORMATION:
Contracting Activity/Customer:
Point of Contact (POC):
Title of POC:
Telephone:
Email:
OFFEROR’S REFERENCE INFORMATION: (to be filled out by the contractor)
Contractor Name:
Point of Contact (POC):
Telephone Number:
Email:
CONTRACT INFORMATION: (to be filled out by the contractor)
Contract Number:
Task Order Number:
Type of Contract:
Performance Period: (Base plus any options):
Solicitation Number
RFP HT001526RE001
Exhibit E
Description of Services:
MAGNITUDE
Annual Contract Value:
Total Contract Dollar Value:
COMPLEXITY
Geographic description of services under this contract:
Approximate number of laboratory tests performed annually under this contract:
| STAT Courier Services provided under this contract: |
| Yes No |
Contractor performed on this contract as:
Prime Subcontractor
Teaming Partner Joint Venture
Please refer to the following assessment definitions to assess the Contractor’s performance in each of the areas listed in this questionnaire:
(E) Exceptional - The Contractor’s performance meets contractual requirements and exceeds many (requirements) to the Government’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the Contractor were highly effective.
(V) Very Good - The Contractor’s performance meets contractual requirements and exceeds some (requirements) to the Government’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the Contractor were effective.
(S) Satisfactory - The Contractor’s performance meets contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the Contractor appear or were resolved satisfactorily.
(M) Marginal - Performance does not meet some contractual requirements. The contractual performance 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.
(U) Unsatisfactory - Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance contains serious problem(s) for which the Contractor’s corrective actions appear or were ineffective.
(NA) Not Applicable – Unable to assess the area.
Quality of Service
| Assess how the Contractor: |
| E |
| V |
| S |
| M |
| U |
| NA |
Provided services that conformed to contract requirements, specifications, and standards of good workmanship.
Submitted accurate reports/surveys.
Utilized personnel that were appropriate to the effort performed.
Established and maintained adequate management of subcontractors to ensure quality service.
If other than “Satisfactory” explain how the performance exceeds or does not meet contractual requirements:
Cost Control
| Assess how the Contractor: |
| E |
| V |
| S |
| M |
| U |
| NA |
Performed the effort within the estimated cost/price.
Submitted accurate invoices on a timely basis.
Demonstrated cost efficiencies in performing the required effort.
The actual costs/rates realized closely reflected the negotiated costs/rates.
If other than “Satisfactory” explain how the performance exceeds or does not meet contractual requirements:
Timeliness/Schedule
| Assess how the Contractor: |
| E |
| V |
| S |
| M |
| U |
| NA |
Performed tasks required under this effort in a timely manner and in accordance with the period of performance of the contract.
Was responsive to technical and/or contractual direction.
Test turnaround time was timely and within the requirements of this effort.
If other than “Satisfactory” explain how the performance exceeds or does not meet contractual requirements:
Business Relationships
| Assess how the Contractor: |
| E |
| V |
| S |
| M |
| U |
| NA |
Demonstrated effective management over the effort performed.
Maintained an open line of communication so that the Contracting Officer’s Representative (COR) was apprised of technical, cost, and schedule issues.
Presented information, reports, surveys and correspondence in a clear, concise, and businesslike manner.
Promptly notified the COR and/or Contracting Officer in a timely manner regarding urgent issues.
Cooperated with the Government in providing flexible, proactive, and effective recommended solutions to critical contract issues.
If other than “Satisfactory” explain how the performance exceeds or does not meet contractual requirements:
Key Personnel
| Assess how the Contractor: |
| E |
| V |
| S |
| M |
| U |
| NA |
Provided qualified personnel to fulfill the requirements of the contract.
If other than “Satisfactory” explain how the performance exceeds or does not meet contractual requirements:
PERFORMANCE SUMMARY
| Would you award this firm another contract: |
| Yes No |
If you answered “No” provide a brief explanation:
| Was the contract terminated for default or cause: |
| Yes No |
If you answered “Yes” please provide an explanation:
Additional Comments:
Date:
Evaluator Signature:
Evaluator Name (Print):
Title:
Telephone: Email:
Thank you for your participation in providing a detailed and accurate history of past performance for this offeror.
File details come from the government source that posted it. Updated .