Attachment_3_-_Past_Performance_Questionnaire.pdf

ATTACHMENT 3 - HHS/ASPR

Developing an Inventory of Trauma, Emergency, and Burn Capabilities in the United States

RFP #HHS-ASPR-16-100-SOL-00035

PART I – Past Performance Contact Information [to be completed by Offeror]

Instructions: The Offeror shall complete Part I of this Attachment for each past performance reference.

The Contractor shall forward this form (with a completed Part I) to each of its references for completion, with instructions to forward the completed questionnaire to the Contracting Officer (NOT BACK TO THE

CONTRACTOR) before the time set for receipt of proposals. The completed questionnaires should be forwarded by email directly from the Contractor’s reference to Patricia.Petersky@hhs.gov and

Carol.Allen@hhs.gov .

Contractor Information:

Name of Contractor Providing Services: ____________________________________________

Address: ____________________________________________________________________

Past Performance Reference Information:

Name of Agency/Organization Receiving Services:

Address: _____________________________________________________________________

Telephone: _________________________ FAX: _____________________________

Contract Information:

Contract Number: _____________________ Dollar Value (Annual): _______________

Performance Period: ___________________ Performance Location: _______________

Type of Contract (Check all that apply):

Fixed Price ______ Cost Reimbursement ______ Other (specify) _________________

Description of Services Provided: ________________________________________________

1. What were you experiences with the quality of the services provided by this Contractor?

Bold or Underline a Rating: 1 2 3 4 5 6 7 8 9 10 N/A mailto:Patricia.Petersky@hhs.gov mailto:Carol.Allen@hhs.gov

ATTACHMENT 3 - HHS/ASPR

Developing an Inventory of Trauma, Emergency, and Burn Capabilities in the United States

RFP #HHS-ASPR-16-100-SOL-00035

2. What were your experiences with the Contractor’s adherence to contract schedules?

3. What were you experiences with the Contractor’s overall ability to meet schedules for delivery of reports?

4. What were you experiences with the Contractor’s ability to meet any special requirements for expedited delivery or service?

5. What were your experiences with the Contractor’s conforming to contract requirements generally?

6. What were your experiences with the Contractor’s standards of professionalism?

7. What were your experiences with the Contractor’s controlling costs and working with you to limit additional costs and, if you are a Government agency, to limit upward equitable adjustments to the

Government’s price in the event of changes?

8. What were your experiences with the Contractor’s integrity and business ethics?

9. What were your experiences with the Contractor’s spirit of cooperation and fairness of business dealing with you?

10. What were your experiences with the Contractor’s commitment to your satisfaction as a customer and concern for your business interests?

11. What were your experiences with the Contractor’s reporting into Government databases to which it was obliged to report?