L-2 Past Performance Questionnaire.docx

L- 2 Past Performance Questionnaire

PAST PERFORMANCE QUESTIONNAIRE

When filled in, this document is source selection sensitive information IAW FAR 2.101 and 3.104

Offeror: Complete SECTION 1, and send a questionnaire to the primary customer point of contact (POC) listed on the Past Performance Information Sheet who is identified as the most familiar with the performance of the effort on the contract.

Primary Customer POC: Complete SECTIONS 2-5 Please complete this questionnaire. Handwritten responses are sufficient. If you need more space, please attach additional pages. If you have any questions, please call the Contracting Officer, Anita Bailey at (937) 255-0466. Please fax the completed questionnaire to: (937) 656-7526.

SECTION 1: CONTRACTOR IDENTIFICATION

SOLICITATION NUMBER: ______________________________

Proposal Volume IV Tab # (Choose One): 1 2 3 4 5 6 7 8

A. Contractor

Other (specify) ______________________

B.1 If Performed as a Subcontractor/Teaming Partner list Prime Contractor:

C. Contract Number

D. Task Order Number (if applicable)

E. Contract Type

No

G. Period of Performance

H. Initial Contract/Task Order Cost ($)

I. Current/Final Contract/Task Order Cost ($)

J. Reasons for differences between initial contract cost and final contract costs (enter below):

SECTION 2: CUSTOMER OR AGENCY IDENTIFICATION

A. Customer or Agency Name

B. Customer or Agency Description (if applicable)

C. Location of services:

D. Description of services:

E. Agency for this contract or task order (choose as many as apply):

|_| Department of Defense medical (Air Force, Army, Navy, TMA, OSD/HA) |_| Other Federal Agency (Provide agency name if different from above) |_| Medical (e.g., hospital, health insurance, or health operations) Please describe below |_| Non-medical Please explain below:

F. Clinical service categories provided under this contract or task order (choose as many as apply):

|_| Allied Health Services - (e.g., physical therapy, occupational therapy, speech pathology, audiology, dietetics, optometry, respiratory therapy, and podiatry).

|_| Ancillary Services – (e.g., radiology, pharmacy, and clinical laboratory) |_| Behavioral Health Services – (e.g., clinical psychology, psychiatry, social work, and psychiatric practitioners).

|_| Dental Services – (e.g., dentistry and dental support).

|_| Nursing Services – (e.g., registered and advanced practice nurses, practical and vocational nurses).

|_| Primary Care Physicians – (e.g., primary care practitioners and physician extenders).

|_| Specialty Care Physicians – (e.g., medical specialties and subspecialties).

|_| Technician/Medical Assistant Services – (e.g., technologists, technicians, and assistants).

|_| Other: Please explain below:

SECTION 3: EVALUATOR IDENTIFICATION

A. Evaluator’s Name

B. Evaluator’s Title

C. Evaluator’s Phone/Fax Number

D. Evaluator’s Mailing Address

E. Number of years evaluator worked on contract

SECTION 4: EVALUATION

Please confirm that your evaluation is consistent with the service provided in Section 2, Paragraph D, Description of Services. Indicate your level of satisfaction with each component of the Contractor’s performance by circling. Please note that Contractors will be given an opportunity to respond to any ratings less than Green/Satisfactory and any negative comments. Indicate your satisfaction with the overall evaluation using the scale provided below and to the right of each question. This scale is defined as follows:

E (Blue) EXCEPTIONAL – The Contractor’s performance meets contractual requirements and exceeds many (requirements) to the Government’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the Contractor were highly effective.

V (Purple) VERY GOOD – The Contractor’s performance meets contractual requirements and exceeds some (requirements) to the Government’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the Contractor were effective.

S (Green) SATISFACTORY – The Contractor’s performance meets contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the Contractor appear or was satisfactory.

M (Yellow) MARGINAL – Performance does not meet some contractual requirements. The contractual performance 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.

U (Red) UNSATISFACTORY – Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance contains serious problem(s) for which the Contractor’s corrective actions appear or were ineffective.

N (White) NOT APPLICABLE – Unable to provide a score.

The Prime Contractor:

For the overall rating, if you indicated E (Blue/Exceptional) or V (Purple/Very Good), describe specifically how the Contractor exceeded contract requirements to the Government’s benefit. If you indicated M (Yellow/Marginal) or U (Red/Unsatisfactory) describe specifically how the Contractor did not meet requirements. Use additional sheets if necessary.

Government Contracts Only: Has/was this contract been partially or completely terminated for default, convenience, or are there any pending terminations?

Yes

No

Default

Convenience

Pending Terminations

If yes, please explain below (e.g., inability to meet cost, performance, or delivery schedules, etc).

SECTION 5: NARRATIVE SUMMARY

What were the Contractor’s most positive aspects in the performance of the contract?

What were the Contractor’s most negative aspects in the performance of the contract?

Would you have any reservations about soliciting this Contractor in the future or having them perform one of your critical and demanding programs?

Please provide any additional comments concerning this Contractor’s performance, as desired.

Evaluator’s Signature Date:

Please Fax completed questionnaire to: 937-656-7526.

Thank you for your prompt response and assistance!