Attachment_3_PPQ.docx

FA3300-19-R-0004

PERFORMANCE QUESTIONNAIRE

A. GENERAL INFORMATION:

Offerors shall forward this attachment for completion to each contract reference the offeror wants the government to consider. Offerors shall ensure each respondent submits a completed questionnaire directly to SSgt Mikel Sessions, Contract Administrator (CA), mikel.sessions@us.af.mil and Kimberly Knott, Contracting Officer (CO), kimberly.knott.1@us.af.mil by the closing date of the RFP. Offerors are encouraged to have respondents submit the information prior to the closing date 3:00PM CT, 23 August 2018.

* Note: If offeror holds or has held other contracts with your agency/organization in the last 3 years, please complete separate evaluation forms for those contracts as well.

B. AGENCY INFORMATION:

Name of Respondent: Title:

Address: Telephone Number:

Email Address:

C. PERFORMANCE INFORMATION:

Respondent shall include information below regarding the work performed. Use the Confident Rating table to complete this section.

Were you the prime contractor? Subcontractor? Joint Venture?

Ambulance, EMS and ALS Services □Yes □No Report of Run Logs Received □Yes □No What was the measured response time in minutes?

Number of unacceptable performance occurrences:

D. PERFORMANCE INFORMATION: Choose the appropriate letter on the scale (E, VG, S, M, U, and N) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF M or U.

E

VG

S

M

U

N

Exceptional

Very Good

Satisfactory

Marginal

Unsatisfactory

Neutral/Not Applicable

Performance meets contractual requirements with many exceeded to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were highly effective.

Performance meets contractual requirements with some exceeded to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with no more than some minor problems for which corrective actions taken by the contractor were effective

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 were satisfactory.

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element 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

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.

Performance was not observed or not applicable to the current effort being reported against.

Home Office/On-Site/Government Interaction

Service Quality

Schedule

Other

Were there any claims by subcontractors/suppliers for non- payment. If yes, please explain outcome in “Remarks”

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? If not, explain in "Remarks."

OVERALL ASSESSMENT

1. Please check any of the services listed below provided by the contractor:

__ Level I Trauma Center

Local, out of town transportation ___ To and From Hospital ___ Nursing/Hospice homes ___ Private Residence ___ Pediatric Intensive Care Unit ___ Neonatal Intensive Care Unit transportation ___ Air Ports ___ Basic Life Support and Advanced Life Support Services

Remarks____________________________________________________________________________