Attachment_4._Past_Performance_Questionaire_11_13_18.pdf

For Official Use Only When completed, this document is Source Selection Information IAW FAR 2.101 and 3.104.

Past Performance Questionnaire

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The 11th Medical Group, Joint Base Andrews, MD of the Air Force District of Washington is in the process of competitively selecting a source for Ambulance and Patient Transport. The contractor will provide 24-hour supplemental ambulance and patient transport services to the 11th Medical Group, located at Joint Base Andrews (JBA), Maryland.

One of the considerations in proposal evaluation is the verification of the offerors' past performance on contracts or other work efforts which reflect the offeror's ability to perform on the proposed effort. We depend on information received from organizations such as yours, which have had first-hand experience with the offeror, for the evaluation of the offeror's performance on those contracts or work efforts.

Our areas of interest regarding the offeror are summarized in the enclosed questionnaire. In order to meet the acquisition milestones, we request your written response no later than___________. This schedule will allow us sufficient time to analyze the data prior to the start of negotiations.

To assist you in preparing your response and expediting your reply, the questionnaire may be filled out electronically and e-mailed to _______________ and __________________. Your completed questionnaire will become a part of the official Source Selection records.

Your assistance is greatly appreciated and your prompt response will be one of the keys to the successful and timely completion of this Source Selection.

1 Atch http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/02.htm#P10_602 http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/03.htm#P41_5836

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Section 1: Contract Identification

A. Contractor (Company/Division):

B. Contractor Cage Code:

C. Contract Number:

D. Contract Type (e.g., FFP, FPIF, CPIF, CPFF, etc.):

E. Program Title:

F. Brief Program Description:

G. Program Phase:

H. Period of Performance

1. Original Schedule (assuming all options exercised):

Beginning Date _________ through ____________

2. Current Schedule (assuming all options exercised):

Beginning Date _________ through ____________

3. Reason for difference (if applicable):

I. Contract Dollar Value

1. Original maximum contract dollar value (assuming all options exercised): $

2. Current maximum contract dollar value (assuming all options exercised): $

3. Reasons for difference between original and current contract dollar value (if applicable):

J. Description of work performed:

K. Was this a competitively awarded contract? ☐ Yes ☐ No

L. Contractor’s Role: ☐ Prime Contractor ☐ Subcontractor ☐ Key Personnel

Section 2: Customer or Agency Identification

A. Customer or agency name:

B. Customer or agency description (if applicable):

C. Geographic description of services under this contract (i.e., local, nationwide, worldwide, other Commands):

Section 3: Respondent Identification

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A. Respondent’s name:

B. Respondent’s title:

C. Respondent’s phone number / fax number / e-mail address:

D. Respondent’s position (e.g., Program Manager, PCO/ACO, etc.):

E. Length of time (number of years/months) respondent worked on subject contract and description of responsibility/position/role:

F. Other suggested points of contact:

Section 4: Performance Information

In the tables below, indicate your rating for the contractor’s performance by placing an “X” in the appropriate block to the right of each question. Provide supporting information for each response in the space provided.

Attach additional pages if more space is needed. The performance rating scale is defined as follows:

Code Performance Rating

E EXCEPTIONAL – Performance meets contractual requirements and exceeds many requirements to the Government’s benefit. The contractual performance being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

V VERY GOOD – Performance meets contractual requirements and exceeds some requirements to the

Government’s benefit. The contractual performance being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

S SATISFACTORY – Performance meets contractual requirements. The contractual performance being assessed contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

M MARGINAL – Performance does not meet some contractual requirements. The contractual performance being assessed 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 being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

N/A NOT APPLICABLE – Unable to provide a rating. Contract did not include performance for this aspect, performance was not observed, or information was not available. Do not know.

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Technical Expertise E V S M U N/A

TE1. Contractor provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements.

SUPPORTING INFORMATION:

TE2. Contractor hired and retained field workers with appropriate technical skills and training commensurate with those required for successful project completion.

TE3. Contractor transported Critical Care, Advanced Life Support (ALS) and Basic Life Support (BLS) patients.

SUPPORTING INFORMATION

TE4. Contractor met designated arrival times as allotted in the contract.

TE5. Contractor had ambulances and staff available 24 hours a day / 7 day a weeks to include holidays with no delays or issues.

TE6. Ambulances were fully staffed with experience and certified paramedics and technicians.

TE7. Ambulances were are 100% functional, insured, and equipped with proper equipment.

TE8. Proper paper work / Run Sheets were provided to the accepting treatment facility upon arrival and transferring of patient.

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Quality of Service E V S M U N/A

QS1. Did the contractor conform to the terms and conditions of the contract?

QS2. Did the contractor comply with the laws, regulations, and facility policies and procedures?

QS3. Contractor provided and followed effective quality control plan to meet contract requirements.

QS4. Contractor corrected deficiencies in a timely manner and pursuant to their quality control procedures.

QS5. Contractor maintained a quality workforce and subcontractors through project completion.

Schedule E V S M U N/A

S1. Delivery of service was within required time period specified by contract requirements.

S2. Contractor provided the required Reports / Documentation as requested within the contract.

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Business Relations E V S M U N/A

BR1. Overall rating of contractor’s business practices (e.g. maintaining A positive working relationship, business ethics, timely and effectively Resolution of any problems, etc.)

BR2. Rate the contractor’s responsiveness to customer complaint resolution.

BR3. Would you award another contract to this contractor? If not, explain.

Government Contracts Only: Was this contract partially or completely terminated for default or convenience, or are there any pending terminations?

☐ Yes ☐ Default ☐ Convenience ☐ Pending Terminations ☐ No

If yes, please explain (e.g., inability to meet cost, performance, or delivery schedules).

SECTION 5: GENERAL COMMENT

Given what I know today about the contractor’s ability to execute what they promised in their proposal, I [ click and select an item ] award to them today given that I had a choice.

REMARKS:

Please provide any additional comments concerning this contractor’s performance, as desired.

[click and pick the date]

Respondent’s Signature Date

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Thank you for your prompt response and assistance!

Please return this completed questionnaire to:

Mailing Address:

[Insert here]

FAX to:

E-Mail to: