J.8_Past_Performance_Questionnaire.pdf

HHSM-500-2015-RFP-0110

Past Performance Questionnaire

PAST PERFORMANCE QUESTIONNAIRE

Sample Cover Letter

[COMPANY LETTERHEAD (Prime or subcontractor)]

Reference Name and Address Date

SUBJECT: HHSM-500-2015-RFP-0110

Dear _________________:

We are currently responding to the Centers for Medicare and Medicaid Services (CMS) request for proposal for the Payment File Development Contractor (PFDC) (as a subcontractor to______ (If applicable)).

There is an increased emphasis on past performance in the federal source selection process.

CMS is requesting that customers and clients of offerors provide the information as described within the attached questionnaire and return it to them for evaluation. We have identified you as one of our references and respectfully request that you complete and sign the attached questionnaire and then return it to CMS.

Questionnaires are due to CMS no later than 12:00 PM EST on Monday, April 13, 2015;

however, we would appreciate an earlier response if at all possible.

We sincerely appreciate your cooperation in this matter.

Sincerely, DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services 7511 Security Boulevard, Mail Stop B2-30-03 Baltimore, Maryland 21244-1850

Office of Acquisition and Grants Management

SUBJECT: HHSM-500-2015-RFP-0110

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 task order with CMS. Please be advised that neither your name, nor position or organization, will be divulged before, during or after this survey has been completed.

The questionnaire is arranged by general performance areas, e.g., quality of service/performance, cost control, timeliness, management, etc. 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 your name and identify your position during your association with the referenced Offeror/Contractor. Once completed, please submit the questionnaire as follows:

Email PDF (Preferred): tessie.fitton@cms.hhs.gov E-mail is the preferred method.

Fax Original: (410) 786-9088, ATTN: Tessie Fitton, (410) 786-2556

(Please advise by phone or e-mail if questionnaire will be faxed)

Mail Original: Centers for Medicare & Medicaid Services

Office of Acquisition and Grants Management ATTN: Tessie Fitton, Contract Specialist

Mail Stop – B3-30-03 7500 Security Boulevard

Baltimore, Maryland 21244-1850

Thank you for taking the time to complete the questionnaire.

Sincerely, Michael J. Connors

Contracting Officer mailto:tessie.fitton@cms.hhs.gov

PAST PERFORMANCE QUESTIONNAIRE

Payment File Development Contractor

Company Being Evaluated (Offeror)

Offeror/Contractor: ___________________________

Address: ___________________________

Evaluation Period: ___________________________

Contract Number: ___________________________

Description of Work: ___________________________

Please complete the following questionnaire about the Offeror/Contractor and indicate your responses in the blocks or columns, as appropriate. Numerical ratings are as indicated in the Rating Scale below for Q1-Q5. Note: Use of the term “Agency” can be interpreted as also Government/non-Government agencies or customers.

Rating Scale:

0 Unsatisfactory: Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

1 Marginal: Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

2 Satisfactory: Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

3 Very Good:

Performance meets contractual requirements and exceeds some to the Government’s benefit.

The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor was effective. No significant weaknesses

4 Exceptional:

Performance meets contractual requirements and exceeds many to the Government’s benefit.

The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor was highly effective. No significant weaknesses

We request that you justify 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.

Q1. Quality: Did the Offeror demonstrate the execution of quality efforts resulted in effective performance outcomes for work activities?

Comments: Rating:

Q2. Cost Control: Did the Offeror demonstrate the ability to ensure costs were within budget?

Q3. Schedule: Did the Offeror demonstrate the ability to consistently meet project milestones and deliverables on time?

Q4. Management: Did the Offeror demonstrate a past track record of notifying its contractors/customers of problems, remaining flexible and reliable, and being responsive to contract requirements and recommending solutions? How well did the offeror match the qualifications of the key position, as described in the contract, with the person that filled the key position? Did the offeror support key personnel so they were able to work effectively?

Q4. Utilization of Small Business: Did the Offeror demonstrate and implement an effective and efficient small/small disadvantaged business subcontracting plan?

Agency/Company COMPLETING Questionnaire

Agency/Company Name: ___________________________

Address: ___________________________

Signature of Individual Completing the Questionnaire: _____________________________ Date

Name: ___________________________ Telephone No.: ________________________

Title: ___________________________ Email Address: ________________________