Attachment L-5 MSS Past Performance Questionnaire.doc

ATTACHMENT L-5 – Medical Support Services 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 the questionnaire to the primary customer point of contact (POC) identified as a reference in your proposal.

Primary Customer POC: Complete SECTIONS 2-5 and sign/date questionnaire.

Handwritten responses are sufficient. If you need more space, please attach additional pages. If you have any questions, please call the Contracting Officer, Ms. Clarinda Smith at DSN 674-5040 (937-904-5040). Please fax the completed 5-page questionnaire to: DSN Fax: 986-7520 (937-656-7520) or e-mail « .pdf » file to clarinda.smith@wpafb.af.mil.

SOLICITATION NUMBER: FA8053-11-R-0003 OFFEROR: ____________________________

SECTION 1: REFERENCE IDENTIFICATION

A. Contractor

Other (specify) ______________________

Teaming Structure/Key Partners

C. Contract Number

(IAW M.6.2.4, single Reference for MAC, task orders, option periods; GSS or GSA are separate references)

D. Contract Type

No

F. Period(s) of Performance (list all option periods, if applicable)

G. Initial Contract Award Amount(4)

H. Total Current/Final Contract Cost ($)

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

J. Description of service provided (enter below):

SECTION 2: CUSTOMER OR AGENCY IDENTIFICATION (Page 2 of 5)

A. Customer or Agency Name

B. Customer or Agency Description (i.e., hospital)

C. Geographic Performance Location under this contract, (i.e., local, nationwide, worldwide, other Command). List States where services were provided below:

D. Provide number of full-time or part-time equivalent positions that were provided by the contract.

Clerical labor categories (i.e., secretary, appointment clerk, office clerk)

Certified labor categories (i.e., medical coding professionals, transcriptionists, records technicians)

Specialized labor categories (i.e., beneficiary services/PEBLO, tumor registrars, referral management personnel, utilization managers, third party collection clerks)

Technical labor categories (i.e., logistics, supply, equipment technicians, public health, safety specialists)

Other labor categories (list them below)

Patient Appointing Service

Medical Records Service

Medical Coding & Auditing Service

Medical Transcription Service

Referral Management Service

SECTION 3: EVALUATOR IDENTIFICATION (Page 3 of 5)

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 subject contract

SECTION 4: EVALUATION

Please confirm that your evaluation is consistent with the description of service provided in Section 1, Paragraph J on Page 1 of the survey. Indicate compliance of the contractor’s performance by placing an “X” in either YES or NO blocks. Indicate your satisfaction is the overall evaluation using the scale provided below:

Demonstrated the ability and willingness to perform requirements for the customer.

Effectively integrated business practices over geographic range and scope of requirements.

Managed teaming partners/subcontractors on this contract.

Implemented sound strategies and contingency plans to safeguard service delivery.

Business Plan rating for business approach and teaming structure.

(CIRCLE ONE)

SECTION 4: EVALUATION (continued) (Page 4 of 5)

Demonstrated a strong recruiting methodology, market knowledge and personnel selection process.

Demonstrated ability to hire and place fully qualified personnel (meeting all education, experience, as well as health and certification requirements) within contracted timeframes.

Demonstrated ability to replace personnel due to planned/unplanned absences or vacancies within the contracted timeframes.

Demonstrated ability to provide personnel that comply with DoD security requirements and are educated about the military healthcare system.

Demonstrated ability to provide trained personnel on DoD computer systems (CHCS/AHLTA), and position requirements.

Managed a qualified workforce and demonstrated day-to-day employee oversight and corporate requirements such as absenteeism, time and attendance, continued education, and appraisals.

Assess employee performance to ensure compliance with performance standards.

Demonstrated a customer satisfaction process and an ability to resolve issues or complaints in a timely manner.

Demonstrated the ability to maintain a stable workforce with minimal turnover of personnel and an overall fill rate of at least 95% annually.

Complied with contract terms and conditions specific to contract bid rates.

Monitored and reported performance measures; provided contract deliverables on time.

Overall contract performance rating. (CIRCLE ONE)

Exceptional Very Good Satisfactory Marginal Unsatisfactory

N/A

SECTION 4: EVALUATION (continued) (Page 5 of 5)

Please discuss each response for any question or rating which you indicated Marginal, Unsatisfactory or Not Applicable in response to the questions above (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 greatest strengths in the performance of the contract?

What were the contractor’s greatest weaknesses 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. Use a separate sheet if necessary.

Evaluator's Printed Name/Title

Evaluator's Signature/Date