Appendix_D_-_PPQ_-_Central_Appointments.pdf

Appendix D – Past Performance Questionnaire

Request for Proposal: FA2823-16-R-6001

CENTRALIZED APPOINTMENT CALL CENTER (CACC)

REFERRAL MANAGEMENT CENTER (RMC)

REGISTRATION AND TRICARE PLUS ENROLLMENT CENTER (RTPEC)

INTERNAL MEDICINE CLINIC APPOINTMENT DESK (IMCAD), Eglin AFB, FL 32542

Name of Contractor: ________________________________________________________

We are currently in the process of preparing our proposal for Solicitation Number FA2823-16-R-6001, to provide Centralized Appointment Call Center Service to the 96th Medical Group at Eglin AFB, Florida. As part of our proposal, we have listed you as a reference on our performance for this type of service, under the previous/current contract listed below, with your company. Your input on our performance is therefore requested. Please complete this questionnaire and e-mail to John Sarver, e-mail john.sarver.2@us.af.mil, or fax to (850) 882-1680. The questionnaire is due no later than the date established for receipt of proposals. Thank you.

1. Contract or Identifying Number:_____________________________________

2. Brief description of scope of work:

3. Period of Performance (Base) _______________________ Amount $_____________

Period of Performance (1st Option) _____________________ Amount $_____________

Period of Performance (2nd Option) ____________________ Amount $_____________

Period of Performance (3rd Option) ____________________ Amount $_____________

Period of Performance (4th Option) ____________________ Amount $_____________

TOTAL: $______________

4. Name of Person Completing Questionnaire: ________________________________

Agency/Company: ______________________________________________________

Title: _____________________________ Phone: _____________________________

Fax: ______________________________ Email:_____________________________

Date:

mailto:john.sarver.2@us.af.mil

EVALUATION. Please rate the Contractor utilizing the guide below. Explanatory narratives for as many responses as possible would be appreciated. These narratives need not be lengthy, just detailed. Attach additional pages if more space is needed..

Assessment Definition

Substantial Confidence

(SC)

Based on the offeror’s recent/relevant performance record, we have a high expectation that the offeror could successfully perform the required effort again.

Satisfactory Confidence

(SAT)

Based on the offeror’s recent/relevant performance record, there is a reasonable expectation that the offeror could successfully perform the required effort again.

Limited Confidence

(LC)

Based on the offeror’s recent/relevant performance record, we have a low expectation that the offeror could successfully perform the required effort again.

No Confidence

(NC)

Based on the offeror’s recent/relevant performance record, we have no expectation that the offeror could successfully perform the required effort again.

Unknown Confidence (Neutral) (UC)

No recent/relevant performance record is available or the offeror’s performance record is so sparse that no meaningful confidence assessment rating can be reasonably assigned.

SC SAT LC NC UC

Provided experienced staff as well as managers with the technical and administrative abilities needed to meet contract requirements.

Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period.

Appointing Staff routinely met required metrics on a monthly/quarterly basis (ex. Abandoned call rate, Service level, hold times).

Contract Personnel were adequately staffed and trained throughout the life of the contract in the central appointments and/or referral management functions.

Contract personnel had minimal customer service complaints from patients and/ or Military Treatment Facility personnel.

Referrals to the Managed Care Support Contractor were processed within the required 72 hour period.

Contract Personnel routinely tracked all referral results to closure NLT 120 days from the order date.

Delegated authority to project managers and supervisors commensurate with contract requirements Home office participated in solving significant local problems Follow approved quality control plan

Provided effective quality control and/or inspection procedures to meet contract requirements

Corrected deficiencies in timely manner and pursuant to their quality control procedures Provided timely resolution of contract discrepancies Identified risks/problems as they occurred

Suggested alternative approaches to problems Displayed initiative to solve problems Met established project schedules Was responsive to contract changes Provided adequate project supervision Cooperated with Government personnel after award Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in "remarks" Would you award another contract to this contractor? YES NO

Overall Rating Assigned _____________________________

BRIEF EXPLANATION OF OVERALL RATING GIVEN:

Overall Rating: _________________________________

ADDITIONAL COMMENTS

DO NOT SEND THE COMPLETED QUESTIONNAIRE TO THE CONTRACTOR.

Evaluator’s Signature Block & Signature Date