Attachment_3_Past_Performance_Questionnaire.pdf

Attachment 3

For Official Use Only

When completed, this document is Source Selection Information IAW FAR 2.101 and 3.104.

Past Performance Questionnaire –

For Official Use Only Page 1 of 5

The 36 Contracting Squadron at Andersen AFB of the Air Force PACAF is in the process of competitively selecting a source for the Andersen Air Force Base Credentials Manager.

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 10 calendar days after your receipt of this letter. 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 niki.brown@us.af.mil. Please call Niki Brown at 671-366-1718 if you have any questions. 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.

NIKI J. BROWN

Contract Specialist 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 mailto:niki.brown@us.af.mil

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Section 1: Contract Identif ication

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. 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. Description of work performed:

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

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

Section 2: Customer or Agency Identif ication

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 Identif ication

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.):

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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 questions below, indicate your rating for the contractor’s performance by checking the appropriate box under 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.

Note: The following are SAMPLE questions. Past Performance evaluation teams MUST construct a simple and concise Past Performance Questionnaire, tailored to seek out key information tied to the significant aspects of the planned acquisition. Avoid questions that can be answered with a “yes” or “no” but instead include probing and direct questions to draw out the required information desired.

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E

Exceptional

G

Good

S

Satisfactory

M

Marginal

U

Unsatisfactory

N

Neutral

A. QUALITY AND TIMELINESS OF SERVICE

1. Receives, establishes and maintains provider credential folders

(PCF) IAW guidance. Provides guidance to providers during the initial and renewal privileging process.

E G S M U N

2. Conducts necessary research of background data to document provider skills to support competency in the requested medical privileges and appropriately credential providers within his/her specialty. Primary source verifies medical, dental and allied healthcare professional credentials documents and information.

3. Conscientiously and independently exercises the authority to reject and/or return unsatisfactory submissions for clinical privileges and determines if any resulting delays warrant the interruption of workflow to perform the missing verifications locally.

4. Briefs newly assigned providers on credentialing procedures and required forms. Provides status changes to Chief of Medical Staff based on known and received data into the PCF.

5. Prepares agenda for credential function meeting, ensures all necessary materials are present for committee member’s review.

Records, prepares and distributes minutes in a timely manner.

6. Establishes, maintains, controls and updates credentials file system to enable quick and efficient retrieval of information.

7. Tracks completion, monitors for trends, maintains reviews in provider files and updates Chief of the Medical Staff.

8. Tracks completion of focused and on-going professional practice evaluations for medical staff appointments/privileging processes.

E G S M U N

9. Routinely collaborates with the process improvement manager and risk manager to assist in collecting on-going performance based provider data as part of the re-privileging process.

E G S M U N

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10. Establishes and maintains CCQAS electronic records, ensuring database is current.

E G S M U N

11. Coordinates with Risk and Quality Managers in the initiation, tracking and completion of Standard/Quality of Care Reviews.

SUPPORTING INFORMATION:

Please provide the following information regarding cost/price:

(1) Original Contract Cost/Price $

(2) Final Contract Cost/Price $

REMARKS:

B. 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).

C. Overall Quality Rating: What is your overall satisfaction with the contractors ability to perform satisfactory

Credential Manager services?

☐ E ☐ V ☐ S ☐ M ☐ U ☐ N/A

REMARKS:

Respondent’s Signature Date

Thank you for your prompt response and assistance!

Please return this completed questionnaire to:

E-Mail to: niki.brown@us.af.mil http://farsite.hill.af.mil/reghtml/regs/far2afmcfars/fardfars/far/03.htm#P41_5836 mailto:niki.brown@us.af.mil