Exhibit D - Past Performance Questionnaire FINAL.pdf
PDF 1 MB Posted
- Attached to
- Clinical Reference Laboratory Testing Services
- Solicitation number
- HT001526RE001FINAL
- Issued by
-
Defense Health Agency
About this file
This document is a Past Performance Questionnaire template (Exhibit D) for RFP HT001526RE001, designed to be completed by past performance references for contractors competing in a Defense Health Agency (DHA) procurement.
The solicitation is for a Single Award Indefinite Delivery/Indefinite Quantity (ID/IQ) contract to provide Reference Laboratory Testing Services supporting DHA Enterprise operations in CONUS and OCONUS regions, encompassing over 6,000 required laboratory tests annually across approximately 200 Military Treatment Facilities. References must complete and submit the questionnaire via email to two designated DHA contracting personnel. The template requires contractors to populate information about themselves, the reference customer, and specific contract details including contract number, task order number, contract type, and performance period. References must document the magnitude of services (annual and total contract values) and complexity factors (geographic scope, approximate number of laboratory tests performed annually, and whether STAT courier services were provided). The questionnaire assesses contractor performance across six evaluation categories—Quality of Service, Cost Control, Timeliness/Schedule, Business Relationships, and Key Personnel—using five assessment levels: Exceptional, Very Good, Satisfactory, Marginal, and Unsatisfactory. References must identify whether the contractor performed as a prime, subcontractor, teaming partner, or joint venture member. The questionnaire concludes with a Performance Summary section requiring the evaluator to indicate whether they would award another contract to the firm and whether the contract was terminated for default or cause, with explanation fields for non-satisfactory responses. The evaluator must provide their name, title, telephone, email, signature, and date.
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Text version
Solicitation Number
RFP HT001526RE001
Exhibit D
EXHIBIT D - 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 Enterprise Medical Services - Contracting Division 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):
mailto:tamara.k.fenwick.civ@health.mil mailto:melissa.l.hearst.ctr.@health.mil
Exhibit D
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:
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.
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.
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.
Exhibit D
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.
Unsatisfactory - Performance does not meet most contractual requirements and recoveryis not likely in a timely manner. The contractual performance contains serious problem(s) for which the Contractor’s corrective actions appear or were ineffective.
Not Applicable – Unable to assess the area.
Quality of Service
Assess how the Contractor: The Contractor’s performance is/was:
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: The Contractor’s performance is/was:
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: The Contractor’s performance is/was:
Performed tasks required under this effort in a timely manner and in accordance with the period of performance of the contract.
Exhibit D
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: The Contractor’s performance is/was:
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: The Contractor’s performance is/was:
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
Exhibit D
If you answered “Yes” please provide an explanation:
Additional Comments:
Evaluator Name (Print):
Title:
Telephone: Email:
Thank you for your participation in providing a detailed and accurate history of past performance for this offeror.
Date:Evaluator Signature
Please refer to the following assessment definitions to assess the Contractor’s performance
| Contracting ActivityCustomer: |
| Point of Contact POC: |
| Title of POC: |
| Telephone: |
| Email: |
| Contractor Name: |
| Point of Contact POC_2: |
| Telephone Number: |
| Email_2: |
| Contract Number: |
| Task Order Number: |
| Type of Contract: |
| Performance Period Base plus any options: |
| Annual Contract Value: |
| Total Contract Dollar Value: |
| Geographic description of services under this contract: |
| Approximate number of laboratory tests performed annually under this contract: |
| If you answered No provide a brief explanation: |
| If you answered Yes please provide an explanation: |
| Additional Comments: |
| Description of Services: |
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