Attachment__5_Past_Performance_Questionnaire.docx

WHEN FILLED IN THIS DOCUMENT IS SOURCE SELECTION SENSITIVE

IAW FAR 2.101 AND 3.104

PAST PERFORMANCE QUESTIONNAIRE

FAX OR E-MAIL COMPLETED SURVEY FORM TO:

FAX TO THE ATTENTION OF: Michael Davidson, Contract Specialist or Diana Thrasher, Contracting Officer, 719-333-9075

E-MAIL: diana.thrasher@us.af.mil or michael.davidson.11@us.af.mil

A. EVALUATED CONTRACTOR’S INFORMATION:

Company/Organization Name

Cage Code:

Point of Contact (POC):

Title of POC:

Address:

Telephone Number:

Fax Number:

Email

B. RESPONDENT INFORMATION:

Respondent’s Name:

Respondent’s Title

Company/Organization Name

Address:

Telephone Number:

C. FULL TIME EQUIVALENTS (FTEs) PROVIDED:

Please provide the specialty title and number of FTEs provided by the evalulated contractor.

D. CONTRACT INFORMATION:

Contract Title/Description:

Contract Number:

Task Order Number if Applicable

Status (i.e. On-going, complete):

Contract Amount: total amount of base plus any options

Type of Contract

Place of Performance:

Total Number of FTEs

E. RATING INFORMATION:

Choose the Rating that most accurately describes the Offeror’s performance or situation.

F. PERFORMANCE EVALUATION QUESTIONS:

Quality of Services

Performance Rating

(1) The Contractor provided quality services that adhered to contract requirements, specifications, and standards of professional conduct.

(2) The Contractor provided quality Health Care Workers (HCWs) that met or exceeded the required qualifications.

(3) The Contractor demonstrated an overall effective and quality management effort.

(4) The Contractor’s ability to assimilate and accommodate changes in contractual requirements and/or priority.

Schedule

Performance Rating

(1) The labor turnover in key personnel and other labor categories (to include contracted HCWs) was minimal and did not adversely affect Contractor Performance.

(3) The Contractor demonstrated the ability to retain incumbent HCWs to support contract/task order requirements so that work schedules would not be disrupted.

(4) The Contractor demonstrated the ability to plan for and provide replacement candidates during the life of the contract to include pre-planned absences, unplanned illnesses, or an extended leave of absence.

(5) The contractor was responsive/timely to administrative functions of the contract.

(6) The contractor met all training requirements in a timely manner.

Business Relations

Performance Rating

(1) The Contractor had the ability to respond effectively to contract performance issues.

(2) Contractor’s overall cooperation relative to this contract.

(3) The Contractor cooperated with the Government in providing flexible, proactive, and effective solutions to critical contract issues.

(4) The Contractor provided proactive and effective management of its subcontractors.

(5) The Contractor was able to resolve customer complaints quickly and effectively.

G. OTHER:

(1) Would you award this firm another contract? ( ) Yes, ( ) No. If you answered “No” provide an explanation. ________________________________________________________________________________________________________________________________________________________________________________________

(2) Was a cure notice_____; show cause notice_____; and/or______ terminated for default issued to this firm during performance of this contract? If you answered “Yes”, provide an explanation. ______________________________________________________________________________

(3) Based upon the information you provided and using the definitions provided in the evaluation criteria above, the overall performance rating you would give this Contractor is:

Exceptional ____ Very Good ______ Satisfactory ______ Marginal ______ Unsatisfactory ______ Unknown ______

COMMENTS: (ALL Unsatisfactory, Marginal, Exceptional or Very Good ratings require comments to support the same. Failure to provide comments will render questionnaire void and will not be evaluated by the Government):

Thank you for you for completing this questionnaire!

Attachment 5