Attachment_4_Past_Performance_Information_Form.docx

RFP FA701417R1001

FOR PAST PERFORMANCE VOLUME II

PAST PERFORMANCE REFERENCES THAT ADDRESSES THE TASK AND FUNCTIONAL AREAS OF THE PWS

Past Performance and Corporate Experience/Knowledge: The Offeror shall have a minimum of three (3) years experience successfully staffing health care providers throughout CONUS. The staffing mix required for this effort is outlined below. The Offeror shall describe their past performance and corporate experience in relationship with the specialties. Each Offeror shall complete this form for each of the task areas with past performance and to validate the corporate knowledge and experience in these areas. A final Past Performance Assessment Rating will be provided as outlined in Attachment 3 - Evaluation Method. There is a 50 page limitation for Volume II Past Performance.

Licensed Clinical Social Worker Mental Health Technician Clinical Psychologist Exercise Physiologist Physical Therapist Human Performance Technician

1. Company/Division Name:

2. CAGE Code:

3. DUNS Number:

(NOTE: If the company or division performing this effort is different than the offeror or the relevance of this effort to the instant acquisition is impacted by any company/corporate organizational change, note those changes. Refer to the “Organizational Structure Change History” provided as part of your Past Performance Volume).

1. Contracting Agency/Customer:

2. Contract Number:

3. Contract Type:

4. Period of Performance:

5. Original Contract $ Value:

(Do not include unexercised options)

6. Current Contract $ Value:

(Do not include unexercised options)

7. If Amounts for 5 and 6 above are different, provide a brief description of the reason:

(Indicate whether it was development and/or production, or other acquisition phase (or Service) and highlight portions considered most relevant to current acquisition)

1. Original Date:

2. Current Schedule:

3. Estimate at Completion:

4. How Many Times Changed:

5. Primary Causes of Change:

(For Government contracts provide current information on all three individuals. For commercial contracts, provide points of contact fulfilling these same roles.)

1. Program/Site Manager:

a) Name

b) Office

c) Address

d) Telephone

e) FAX Number

f) E-Mail Address

2. Contracting Officer:

a) Name

b) Office

c) Address

d) Telephone

e) FAX Number

f) E-Mail Address

3. Administrative Contracting Officer:

a) Name

b) Office

c) Address

d) Telephone

e) FAX Number

f) E-Mail Address

(Specify any key individual(s) who participated in this program and are proposed to support the instant acquisition, to include their contractual roles for both acquisitions.)

Contractual Role Proposed Contractual Role

(Include relevant information concerning your compliance on the submitted contract.)

(Identify whether a subcontracting plan was required by the contract you are submitting. If so, identify, in percentage terms, the planned versus achieved goals during contract performance. If goals were not met, please explain.)

Subcontracting Plan Required: YES NO (Mark One)

a) Small Business

b) Small Disadvantaged Business

c) Service Disabled Veteran Owned Business

d) Veteran-Owned Small Business

e) Women-Owned Small Business

f) HUBZone Small Business

Explanation if goals were not met:

(Describe the nature or portion of the work on the proposed effort to be performed by the business entity being reported here. Also, estimate the percentage of the total proposed effort to be performed by this entity and whether this entity will be performing as the prime, subcontractor, or a corporate division related to the prime (define relationship)).

(The offeror may provide additional information or explanation for Items A through L, above, if necessary. The offeror must clearly identify the applicable Item(s) by Letter/Number for which the additional information or explanation applies.)