PastPerfQuest. Physician Liaison FY12.doc

PAST PERFORMANCE INFORMATION QUESTIONNAIRE

UPON INSERTION OF INFORMATION THIS DOCUMENT BECOMES

SOURCE SELECTION SENSITIVE IN ACCORDANCE WITH FAR PART 3.104

A. GENERAL INFORMATION:

Contractor’s Name:

Telephone Number:

Fax Number:

Point of Contact:

Email:

Address:

Project Title or Brief Description of Work:

Contract Number Provided by Offeror : Dollar Amount$

Contract Period or Dates of Performance:

Contract performed as the □ Prime Contractor □ Sub-Contractor □ Key Personnel

B. RESPONDENT INFORMATION

Name of Respondent: Title:

Address: Fax Number:

Email Address:

C. E-MAIL OR FAX COMPLETED SURVEY FORM TO: liviana.borghese@aviano.af.mil or 0039-0434-307938.

D. PERFORMANCE INFORMATION: In this section of the questionnaire, you are asked to rate the contractor. Please indicate the rating that best applies. You may provide comments at the end of this document if you desire to elaborate on any of your answers. Please use additional sheets of paper if more space is needed.

TABLE 5- PERFORMANCE CONFIDENCE ASSESSMENTS

NO

CONFIDENC(NC)

Based on the offeror’s recent/relevant performance record, the government has no expectation that the offeror will be able to successfully perform the required effort.

A. SERVICE QUALITY

1. Contractor’s ability to meet minimum quality standards specified for performance.

2. Contractor’s ability to effectively control the quality of services provided.

3. Contractor’s compliance with contractual terms and conditions.

4. Was re-performance of non conforming services services frequent.

5. Has a Contract Discrepancy Report ever been issued?

B. RESPONSE TIMES

1. Contractor’s ability to meet specific response times and scheduled time frames of specific tasks.

2. Contractors responsiveness/timeliness in providing administrative documents required by contract.

3. Contractor’s timeliness in responding to emergency service requirements (if foreseen by the contract).

C. BUSINESS RELATIONS

1. Contractor’s ability to identify problems or potential problems and promptness in notifying the Contracting Officer.

2. Contractor’s ability to correct problems and prevent or mitigate potential problems in a timely manner.

3. Contractor’s willingness to improve and correct non compliance issues or concerns.

4. Contractor’s ability to use effective approaches and provide technical expertise and resources to solve contract problems.

5. Extent to which the contractor has demonstrated reasonable and cooperative behavior.

6. Contractor’s working relationship with the Contracting Agency’s personnel.

7. Contractor’s flexibility to adjust to requirements changes.

D. MANAGEMENT

1. Did Contractor dedicate adequate financial and human resources to the contract to meet its scope and objective(s)

1. Contractor’s ability to select and retain cooperative and effective key personnel, such as but not limited to bilingual service call center and quality control personnel.

2. Extent key personnel were knowledgeable about contractual requirements.

3. Contractor’s ability to provide adequately qualified personnel.

E. COMPLIANCE WITH ENVIRONMENTAL, SAFETY, HEALTH AND SECURITY REQUIREMENTS

1. Has the contractor received any notices of violations for noncompliance with environmental laws and regulations?

2. Has the contractor received any notices of violations for noncompliance with personnel safety requirements.

F. CONTRACTUAL CONSIDERATIONS

1. Has an election ever been made not to exercise an option or continue relations due to contractor’s poor performance?

2. Has a cure notice or show cause ever been issued?

3. Did Contractor fail to observe any labor laws, collective bargaining agreements, use illegal labor etc?

4. Extent to which the contractor provided reliable, supportable cost estimates or proposals for contract changes or spare parts/materials.

G. OVERALL RATING OF CONTRACTOR

1. Overall rating of contractor’s performance under this contract.

2. Would you award another contract to this contractor?

REMARKS: (Please provide any desired rating elaboration and pertinent general comments in relation to the Contractor’s contractual obligations) (Use additional sheets if necessary).

ATTACHMENT #2