Attachment_J.8-_Past_Performance_Questionnaire.docx
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- HHSM-500-2013-RFP-0030
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop B3-30-03 Baltimore, Maryland 21244-1850
Office of Acquisition and Grants Management
SUBJECT: HHSM-500-2013-RFP-0030, Past Performance Questionnaire
To Whom It May Concern:
The Centers for Medicare & Medicaid Services (CMS) very much appreciates your time and thoughtfulness in completing the attached questionnaire. The information obtained from this questionnaire will be utilized to evaluate the past performance of Offerors/Contractors who wish to be awarded a contract with CMS. Please be advised that neither your name, nor position or organization will be divulged either before and/or during this survey.
The questionnaire is arranged by general performance areas, e.g., Quality of Products/Services, Schedule, Cost Control, Business Relations and Management of Key Personnel. Each area consists of a few basic questions relating to these aspects of performance with regard to the Offeror/Contractor with which you worked. Please complete the questionnaire as indicated on the form.
Finally, please sign (electronic signature(s) are acceptable) your name and identify your position during your association with the referenced Offeror/Contractor. Once completed, please submit the questionnaire in one of the following manners:
| Email: | Ella.Curtis@cms.hhs.gov |
| E-mail (electronic submission) is the preferred method. |
| Mail Original: | Centers for Medicare and Medicaid Services | |
| OAGM/ASG/DPIFMC |
M/S B3-30-03
| ATTN: Ella Curtis |
| Contract Specialist |
| 7500 Security Blvd. |
| Baltimore, MD 21244-1850 |
If you should have any questions, comments and/or concerns please contact Ella Curtis at (410) 786-1227 and/or email at Ella.Curtis@cms.hhs.gov.
Sincerely, /s/
Edward M. Rutherford Contracting Officer
PAST PERFORMANCE QUESTIONNAIRE
HHSM-500-2013-RFP-0030
Offeror/Contractor: ____________________________________________ (Company who is submitting a proposal)
Address: ____________________________________________
Telephone #: ____________________________________________
Email: ____________________________________________
Please complete the following questionnaire about the Contractor (Offeror) named above; and, indicate your responses in the blocks and/or columns, as appropriate on pages 4 through 5
Adjectival ratings are as indicated in the Rating Scale are on page 3.
The individual completing this information will provide the information requested on Page 6.
Note(s): Use of the term “agency” can be interpreted as either a Government and/or non-Government organization.
Please do not leave any section blank. If you are unsure and/or a question does not apply, please indicate your response as “not applicable” (N/A).
Rating Scale:
| ADJECTIVE |
| DEFINITION AND CRITERIA |
| Excellent |
| Their performance merits and reflects an excellent approach which clearly resulted in a superior attainment of all requirements and objectives. Their clearly achievable approach included numerous advantageous characteristics of substance, and essentially no disadvantages, which resulted in outstanding performance. Their solutions were low risk in that they were exceptionally clear and precise, fully supported, and demonstrate a clear understanding of the requirements. |
| Very Good |
| Their performance demonstrated a sound approach which met all requirements and objectives. Their sound approach included advantageous characteristics of substance, and few relatively minor disadvantages, which collectively resulted in satisfactory performance. Their solutions were considered feasible and practical. These solutions reflected low risk in that they were clear and precise, supported, and demonstrate an understanding of the requirements. |
| Satisfactory |
| Their performance demonstrated an approach which was capable of meeting all requirements and objectives. Their approach included both advantageous and disadvantageous characteristics of substance, where the advantages were not outweighed by the disadvantages. Collectively, the advantages and disadvantages resulted in acceptable performance. Their risk of unsuccessful performance was moderate, as their solutions were generally feasible and practical. Their solutions were further considered to reflect moderate risk in that they were somewhat clear and precise, partially supported, and demonstrate a general understanding of the requirements. |
| Marginal |
| Their performance demonstrated an approach which was capable of meeting all requirements and objectives. Their approach had disadvantages of substance and advantages, which if they existed, were outweighed by the disadvantages. Collectively, the advantages and disadvantages were not likely to result in satisfactory performance. Their risk of unsuccessful performance was high as their solutions may not have been feasible and practical. Their solutions were further considered to reflect high risk in that they lacked clarity and precision, were generally unsupported, and did not demonstrate a complete understanding of the requirements. |
| Unacceptable |
| Their performance demonstrated an approach which was based on a very high risk, very likely not be capable of meeting all requirements and objectives. Their approach had numerous disadvantages of substance, and advantages which, if they exist, were far outweighed by disadvantages. Collectively, the advantages and disadvantages did not result in satisfactory performance. The risk of unsuccessful performance was very high as the solutions were not feasible and practical. Their solutions were further considered to reflect very high risk in that they lacked any clarity or precision, were unsupported, and did not demonstrate an understanding of the requirement. |
Although not required, we request that you explain each of your ratings with a comment. Please be as specific in your comment as possible, especially in situations that warrant very high or very low ratings. Use extra pages as necessary or expand the form electronically as needed.
| Past Performance Evaluation |
| Overall Rating |
| E |
| VG |
| Sat |
| M |
| U |
Past Performance - Overall
Past Performance in performing as the National Supplier Clearinghouse Medicare Administrative Contractor (NSC MAC) responsible for issuing or revoking Medicare supplier billing privileges for suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).
How would you rate the contractor's OVERALL PERFORMANCE for this effort?
Would you award this contractor another similar contract? YES ( ) NO ( )
Comments:
| E |
| VG |
| Sat |
| M |
| U |
Quality of Products/Services - compliance with contract requirements; conformance to standards of good workmanship; quality and accuracy of reports; appropriateness of assigned personnel; technical excellence; customer satisfaction.
Comments:
| E |
| VG |
| Sat |
| M |
| U |
Schedule - Adhered to the contract schedule
Comments:
| Past Performance Evaluation Continued |
| E |
| VG |
| Sat |
| M |
| U |
Cost Control - Within budget; current, accurate and complete billings; costs properly allocated; unallowable costs not billed; relationship of negotiated costs to actual; and cost efficiencies.
Comments:
| E |
| VG |
| Sat |
| M |
| U |
Business Relations - effective and efficient management; businesslike correspondence; responsive to contract requirements and technical direction; prompt notification of problems; reasonable/cooperative behavior; flexible; pro-active; effective and efficient contractor recommended solutions.
Comments:
| E |
| VG |
| Sat |
| M |
| U |
Management of Key Personnel - effective and efficient management of work force; work force properly trained and given proper direction to ensure that required tasks are successfully performed; responsive to contract requirements; reasonable/cooperative behavior.
Comments:
Past Performance Contract Data for Contractor Listed on Page 2.
CONTRACT NUMBER: _________________________________________________
CONTRACT TITLE: _____________________________________________________
TYPE OF CONTRACT: ___________________________________________ _____
PERIOD OF PERFORMANCE: __________________________
DOLLAR VALUE OF CONTRACT: _____________________
SUMMARY OF SERVICES PROVIDED: _________________ ___________________
SUMMARY OR ADDITIONAL COMMENTS: _________________ _________________
Company (reference) COMPLETING the Questionnaire (Pages 4 & 5)
Company Name: ___________________________________________________________
Point of Contact: ________________________________ Title: ______________________
Address: ___________________________________________________________
(CITY) (STATE) (ZIP CODE)
Telephone No.: _______________________ Email: ____________________________
| Individual Completing the Questionnaire: _______________________ | ________ | ||
| Signature | Date |
Note: The Questionnaire may be submitted with an electronic and/or scanned signature (information).
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