PAST PERFORMANCE QUESTIONNAIRE4- Inpatient Transcription.pdf

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

REVISED 24 Aug 09

Contractor’s responding to solicitation FA4427-09-R-0009 shall send this Past Performance

Questionnaire for their references to fill out.

A. GENERAL INFORMATION: Please correct any information below known to be inaccurate:

“Contractor Name = the contractor responding to the solicitation.”

Contractor’s Name: ____________________ Telephone Number: ____________________ Address: __________________________ Fax Number: _________________________ __________________________ Point of Contact: ______________________

Project Title and Brief Description of Work: ____________________________________*

Contract Number Provided by Offeror: ___________________ Dollar Amount: ________

Please indicated at what performance threshold the contractor performed, in regards to the number of lines transcribed on an average year:

____900,000 or more ____800,000-899,999 ____700,000-799,999 ____699,999 or fewer

In an average six months of performance, please indicate at what threshold the contractor performed in regards to accuracy, within a turn-around-time of 24 hours (4 hours for STAT reports)? Check one below:

____98% or higher ____90%-97% ____85%-89% ____84% or below

Contract Period or Dates of Performance Provided by Offeror: ______________________* Contractor performed as the Prime Contractor Sub-Contractor Key Personnel.

B. RESPONDENT INFORMATION:

“Respondent = Name of the Reference filling out the Questionnaire”

Name of Respondent: _____________________ Title: ____________________________ Facility Name: _____________________ Address: _____________________ Telephone Number: ___________________ _____________________________ Fax Number: ______________________ _____________________________ Email Address: ______________________

C. FAX or E-MAIL COMPLETED SURVEY FORM TO: PLEASE SEND NO LATER THAN 4:30 PM (PST) 28 Aug 09 to Jessica Pritchett at (707) 424-0288 or jessica.pritchett@travis.af.mil

D. PERFORMANCE INFORMATION: Choose the appropriate letter on the scale (1, 2, 3, 4, and 5) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 4 or 5.

1 2 3 4 5

Substantial Confidence

Satisfactory Confidence

Limited Confidence

No Confidence Unknown Confidence

Based on the offeror’s performance record, the government has a high expectation that the offeror will successfully perform the required effort.

Based on the offeror’s performance record, the government has an expectation that the offeror will successfully perform the required effort.

Based on the offeror’s performance record, the government has a low expectation that the offeror will successfully perform the required effort

Based on the offeror’s performance record, the government has no expectation that the offeror will successfully perform the required effort

No performance record is identifiable or the offeror’s performance record is so sparse that no confidence assessment rating can be reasonably assigned.

Place an “X” in the appropriate column using the definitions matrix above.

The contractor: 1 2 3 4 5

1. Provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements.

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

3. Delegated authority to project managers and supervisors commensurate with contract requirements.

4. Home office participated in solving significant local problems.

5. Followed approved quality control plan.

6. Corrected deficiencies in timely manner and pursuant to their quality control procedures.

6. Identified problems as they occurred.

8. Displayed initiative to solve problems.

9. How would you rate the contractor's overall performance?

10 Would you award another contract to this contractor? If not, explain in “remarks

YES/NO

CONTRACTOR’S NAME: ___________________ CONTRACT NUMBER __________

Remarks: