Attach_3_Past_Performance_Survey.pdf

FA7000-13-T-0064

Past Performance Survey

Attachment 3

** FOR GOVERNMENT USE ONLY ONCE COMPLETED **

MEMORANDUM FOR _______________________________________

SUBJECT: Request for Past Performance Evaluation

FROM: 10 CONS/LGCB

8110 Industrial Drive, Suite 200

USAF Academy, CO 80840

1. You have been identified as a point of contact for a past performance evaluation of the firm identified on the attached survey. This firm is currently interested in providing Ambulance

Services at the United States Air Force Academy, CO.

2. Please complete the attached survey questionnaire. You may email the survey to londres.medranda@us.af.mil or aaron.schulz@us.af.mil. Documents may also be faxed to my attention at 719-333-9075.

3. Your contribution and prompt attention to this questionnaire is greatly appreciated. To be considered timely, responses MUST be received no later than 1:00pm Mountain Local Time on 21Oct 2013. If you have any questions, please contact Londres Medranda, Contract

Specialist, at londres.medranda@us.af.mil or 719-333-8927.

//SIGNED//

AARON SCHULZ

Contracting Officer

Attachment:

mailto:londres.medranda@us.af.mil mailto:aaron.schulz@us.af.mil mailto:londres.medranda@us.af.mil

PAST PERFORMANCE SURVEY

This attachment will not be incorporated into the resultant contract.

THIS DOCUMENT, WHEN COMPLETED, IS ONLY FOR VIEW BY THE GOVERNMENT.

This survey is for the United States Air Force Academy Contracting Office.

10th Contracting Squadron

Phone: 719-333-8927

Fax: 719-333-9075

Brief Description of Services to be Required:

The contractor shall provide full emergency patient response services at the United States Air Force

Academy (USAFA) to include but not limited to the USAFA flight line, cadet area, community center, Jacks Valley, Pine Valley housing area, and Douglass Valley housing area (all locations will be referred to as USAFA hereafter). During jump and flight line operations, a dedicated ambulance shall be physically located at the jump site. The contractor shall participate in USAFA base exercises, special events, sports/athletic events, specialized training, and in-flight emergencies. The contractor shall furnish all labor, management, supervision, vehicles, supplies, equipment, and transportation except as provided in Section 3 of the Performance Work Statement. The contractor shall, at a minimum, be responsible for providing the full range of Emergency Medical Technician (EMT), paramedic, and ambulance services provided in the local community to include County protocols or standing orders and staffing minimums in accordance with State of Colorado regulations and protocols. Performance shall comply with the requirements contained in the Performance Work Statement (PWS) and professional standards of the

Accreditation Association of Ambulatory Health Care (AAAHC) and the Colorado State Department of

Public Health and Environment, Health Facilities and Emergency Medical Services Division.

I. CONTRACT INFORMATION:

(Offeror will fill out Section I before sending the survey to the respondent.)

Contractor’s Name: ____________________________________________________________________

Address: ____________________________________________________________________________

Telephone Number: ____________________________________________________________________

Point of Contact: ______________________________________________________________________

Project Title or Brief Description of Work: Provide a description of the contract effort that identifies the key requirements and/or type of effort.

Contract Number: ____________________________________________________________________*

Contract Value Per Year: _______________________________________________________________

Contract Period or Dates of Performance: _________________________________________________*

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

II. SURVEY RESPONDENT INFORMATION:

Complete the following information on your company. You may be contacted for additional information pertaining to the past or present performance of the contractor identified in the section above. (The following information will assist in the analysis of the data. Information will be kept confidential.)

Name of Respondent: __________________________________________________________________

Company/Organization: ________________________________________________________________

Title: _______________________________________________________________________________

Address: _____________________________________________________________________________

Telephone Number: ___________________________________ Fax Number: _____________________

Relationship and time involved with Program/Contract:

Date you completed this questionnaire: ____________________________________________________

III. PERFORMANCE INFORMATION:

Choose the description of the contractor’s work that best reflects their performance using the descriptions provided below. Please provide a narrative explanation for any ratings of unsatisfactory, marginal, very good or exceptional and any other specific problems or annotations that would help us evaluate the contractor.

E VG S M U N/A

Exceptional Very Good Satisfactory Marginal Unsatisfactory Not Applicable

The contractor met and exceeded many of the requirements of the contract and consistently performed at a superior level.

Performance was accomplished with very few minor problems, and the contractor took immediate and effective corrective actions for

The contractor met and exceeded some of the requirements of the contract and consistently performed very well.

Performance was accomplished with some minor problems, and the contractor took timely and effective corrective action for those

The contractor met the requirements of the contract and consistently performed at an acceptable level.

Performance was accomplished with some problems, and the contractor took effective corrective action for those problems that did occur

The contractor did not always meet some of the requirements of the contract and intervention was required to continue performance.

There were instances where performance was at a less than acceptable level;

performance was accomplished

The contractor did not meet the requirements of the contract and performance was at an unacceptable level. There were a number of serious problems that required extensive oversight and involvement, and corrective actions were either ineffective or

Unable to provide a rating.

Contract did not include performance for this aspect, or information is not available. Do not know.

those problems that did occur.

problems that did occur with some problems and some corrective actions appear only marginally effective or were not fully implemented non-existent

PLEASE ANSWER ALL QUESTIONS. PLEASE PROVIDE ADDITIONAL COMMENTS FOR EACH

QUESTION.

MANAGEMENT

1 Was the contractor able to obtain and hold required certifications and licenses to operate an ambulance?

COMMENTS:

E V

G

S M U N/

A

2 How well did the contractor implement emergency response procedures and coordinate with other emergency responders?

S M U N/

A

3 How well did the contractor implement fair and reasonable billing practices?

S M U N/

A

4 How well did the contractor comply with the Health regulations? (i.e. Joint

Commission, AAAJA and Colorado State Dept of Public Health and Environment)?

S M U N/

A

QUALITY

5 How effective was the contractor in meeting any surge in emergency responses?

S M U N/

A

6 Assess the contractor’s ability to meet required emergency response time thresholds?

Please elaborate with percentages.

S M U N/

A

7 Assess the contractor’s ability to provide medical care appropriate to a patient’s condition?

S M U N/

A

OVERALL

8 Were there any negative performance aspects of the contractor?

If yes, please comment.

YES NO

9. ADDITIONAL COMMENTS:

Thank you for completing this survey.

The completed survey is to ONLY be viewed by the Government. Do not submit a copy of the completed survey to anyone other than Londres Medranda, Contract Specialist, or Aaron Schulz, Contracting

Officer.

FAX or E-MAIL COMPLETED SURVEY FORM TO:

FAX: ATTN: Londres Medranda, Contract Specialist or Aaron Schulz, Contracting Officer, 10

CONS/LGCB, FAX (719) 333-9075

EMAIL: londres.medranda@us.af.mil or aaron.schulz@us.af.mil

****FOR OFFICIAL USE ONLY, ONCE COMPLETED****