Attachment_4 _PPQ.pdf

Attachment 4

FA5613-15-R-0020

For Official Use Only

PAST PERFORMANCE QUESTIONNAIRE

This acquisition is for medical standards management element technician support services (MSME), supporting

Separation History and Physical Examinations (SHPE) at Ramstein Air Base, Germany.

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

Contractor’s Name: ____________________ Address:

Telephone Number: ____________________

Email Address: ____________________

Point of Contact: ____________________

Project Title or Brief Description of Work*:

Contract Number*: Contract Amount:

Contract Period or Dates of Performance*:

Contractor performed as the Prime Contractor Sub-Contractor Key Personnel.

To be completed by the respondent and returned directly to the contracting office.

* Note: If offeror holds or has held other contracts with your agency/organization in the last 5 years, please complete separate evaluation forms for those contracts as well.

B. RATER INFORMATION:

Name of Rater: _____________________ Name of Rater: _____________________

Title: _____________________ Title: _____________________

Address: _____________________ OR Address: _____________________

Phone Number: _____________________ Phone Number: _____________________

Email Address: _____________________ Email Address: _____________________

C. RETURN COMPLETED SURVEY FORM WITHIN 4 WORKING DAYS AFTER RECEIPT TO:

Andrew Grocott/Contract Specialist Ingeborg Jenkins/Contracting Officer

700 CONS/LGCA and 700 CONS/LGCA andrew.grocott@us..af.mil ingeborg.jenkins.1.de@us.af.mil

+49-631-536-6954 or DSN 489-6954 +49-631-536- 6800 or DSN 489-6800 mailto:andrew.grocott@us..af.mil mailto:ingeborg.jenkins.1.de@us.af.mil

CONTRACTOR’S NAME: CONTRACT NUMBER:

D. PERFORMANCE INFORMATION: Choose the appropriate letter on the scale (E, G, 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 G S M U N

Exceptional Good Satisfactory Marginal Unsatisfactory Neutral

Performance meets contractual requirements with many exceeded to your organization’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 your organization’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.

CONTRACTOR’S NAME: CONTRACT NUMBER:

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

The contractor: E G S M U N

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

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

3. Did contractor assign personnel with required skills to accomplish the work?

4. Did contractor personnel provide timely and accurate information/performance to all administration support tasks?

5. Did contractor personnel create/provide proper and accurate schedules/templates in patient appointment computer system (if applicable)?

6. Provided effective quality control and/or inspection procedures to meet contract requirements.

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

8. Provided timely resolution of contract discrepancies.

9. Identified problems as they occurred.

10. Suggested alternative approaches to problems.

11. Displayed initiative to solve problems.

12. Provided timely resolution of defects.

13. Was responsive to contract changes.

14. Provided adequate project supervision.

15. Contractor personnel were professional in appearance

16. Contractor personnel were professional in their interactions with patients

17. Complied with environmental requirements, if applicable.

18. Did contractor consistently respond within the required time frames?

19. For US Government contracts only: Followed Government accepted Quality

Control Plan.

20. For US Government contracts only: Cooperated with Government personnel after award.

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

22. For US Government contracts only Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.”

YES / NO

23. For US Government contracts only: Is the contractor rated in CPARS? YES / NO

24. Would you award another contract to this contractor? If not, explain in “remarks.” YES / NO

Remarks: