Attachment_4,_Questionnaire.pdf

Attachment 4

FA3010-17-R-0026

02 Aug 17

F A3 0 1 0 -1 7 -R -0 0 2 6PAST PERFORMANCE QUESTIONNAIRE

A. OFFEROR’S REFERENCE INFORMATION:

Contract Name and/or Number

(include task order number(s) if applicable)

Company/Division Name to be evaluated

Address:

Point of Contact (POC):

Title of POC:

Telephone Number:

Email

Contractor performed as: Prime contractor

Contractor performed as: Sub-Contractor

Joint Venture Affiliate To/With

B. RESPONDENT INFORMATION: Please complete.

Contracting Activity/Customer

Address:

Telephone Number:

Email Address:

Point of Contact (POC):

Title of POC:

Keesler AFB is in the process of soliciting offers from companies capable of providing:

One (1) Full-Time Equivalent (FTE) OR Nurse/Scheduler

In order for the 81st Contracting Squadron to conduct its evaluation, we request that you complete the questionnaire below and e-mail a PDF file to michelle.brown.1@us.af.mil, Contract Specialist, at 81 CONS, Keesler AFB. The due date for completed questionnaires is: 08/22/2017 at 1:30 PM CST. Your completed questionnaire will become a part of the official source selection records. To be considered, the Past Performance

Questionnaire shall be returned to the Contract Specialist in its entirety and by the due date and time specified above.

To confirm receipt of your completed/submitted questionnaires please contact Contract Specialist, Michelle

Brown, by e-mail at michelle.brown.1@us.af.mil or by telephone at 228-377-1801.

mailto:usarmy.detrick.medcom-nrmc.mbx.hcaa-nrmc@mail.mil mailto:usarmy.detrick.medcom-nrmc.mbx.hcaa-nrmc@mail.mil mailto:michelle.brown.1@us.af.mil

02 Aug 17

0 2 A u g 1 7

F A3 0 1 0 -1 7 -R -0 0 2 6 PAST PERFORMANCE QUESTIONNAIRE

C. CONTRACT INFORMATION: Please complete.

Contract Name and/or Number

Task Order number:

Type of Contract:

Performance Period: (Base plus any options):

Performance Period for the task order:

Annual Contract Values:

Total Contract Dollar Value: (base plus any options)

Number of FTEs / Session-based:

Contract Description:

Contractor performed as: Prime contractor

Contractor performed as: Sub-Contractor Joint Venture Affiliate To/With

What percentage of the contract was performed by the evaluated contractor, if available: ………………...%.

02 Aug 17

0 2 A u g 1 7

Instructions:

Please provide ratings and comments regarding the Contractor’s performance in each area below using the following ratings.

RATING DEFINITION

Exceptional

Performance meets contractual requirements and exceeds many to the

Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Very Good

Performance meets contractual requirements and exceeds some to the

Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Satisfactory Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Marginal

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being evaluated reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Unsatisfactory

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective

N/A Not Applicable

PAST PERFORMANCE QUESTIONNAIRE

Exceptional

Very

Good

Satisfactory

Marginal

Unsatisfactory

N/

A

A. QUALITY OF SERVICE AND PERFORMANCE

(1) The Contractor provided quality service that adhered to contract requirements, specifications, and standards of professional conduct.

(2) The Contractor consistently responded to problems and took appropriate action to correct performance.

(3) Did the contract involve hard to fill positions (specialty positions) or positions are remote locations? If so, Contractor successfully recruited and retained qualified

Ancillary HCPs with minimal disruption.

B. MANAGEMENT

(1) Contractor was able to resolve customer complaints quickly and effectively.

02 Aug 17

0 2 A u g 1 7

(2) Contractor demonstrated an overall effective and quality management effort.

(3) Contractor cooperated with the

Government in providing flexible, proactive and effective solutions to critical contract issues.

C. TIMELINESS/ SCHEDULE OF PERFORMANCE/SERVICES

(1) Contractor demonstrated ability to plan for and provide replacement candidates during the life of the contract to include pre-planned absences, unplanned illnesses, or an extended leave of absence.

(2) The Contractor consistently demonstrated an ability to quickly recruit and retain qualified HCPs in accordance with contract requirements and to avoid disruption of services and/or work schedule.

(3) Credentialing Packages (to include current and complete information) were presented in timely fashion to the applicable facility.

D. OTHER:

(1) Would you award this firm another contract? ( ) Yes ( ) No

If you answered “No” provide an explanation.

(2) Was the contract terminated for default or cause? ( ) Yes ( ) No

If you answered “Yes”, provide an explanation._

(3) Has the Contractor been given a cure notice, show cause notice, suspension of progress payments in the last 3 years. ( ) Yes ( ) No

If you answered “Yes”, provide an explanation and how many actions and if they were resolved:

(4) ADDITIONAL COMMENTS: