J.11_Past_Performance_Questionnaire.docx
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- Attached to
- MACRA Quality Improvement Direct Technical Assistance Federal contract opportunity
- Solicitation number
- HHSM-500-2016-RFP-0021
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Attachment J.11 PPQ
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HHSM-500-2016-RFP-0021
Attachment J.11 Past Performance Questionnaire
PAST PERFORMANCE QUESTIONNAIRE
CMS Solicitation No. HHSM-500-2016-RFP-0021
(Company Being Evaluated) (Offeror)
| Offeror/Contractor: | ___________________________ | |
| Address: | ___________________________ | |
| ___________________________ |
Name of Contracting Activity:____________________________________________________ Brief Description of Work: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Contract Type:________________________________________________________________________ Total Contract Value:___________________________________________________________________ Performance Period:____________________________________________________________________ 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. Other Ratings are as indicated in each block.
Rating Scale:
| N/A |
| Not Applicable: Question does not apply to the contract discussed in this report |
| 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/Business Entity’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. |
| 4 |
| Exceptional: Performance meets contractual requirements and exceeds many to the Government/Business Entity’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. |
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?
| Comments: |
| Rating: |
Q3. Schedule: Did the Offeror demonstrate the ability to consistently meet project milestones and deliverables on time?
| Comments: |
| Rating: |
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?
| Comments: |
| Rating: |
Q4. Utilization of Small Business: Did the Offeror demonstrate and implement an effective and efficient small/small disadvantaged business subcontracting plan?
| Comments: |
| Rating: |
Agency/Company COMPLETING Questionnaire
Agency/Company Name: ___________________________
Address: ___________________________
Signature of Individual Completing the Questionnaire: ____________________________________ Date
Name: ___________________________ Telephone No.: ________________________
| Title: | ___________________________ | Email Address: | ________________________ | |
| Source Selection Information – See FAR 2.101 and 3.104 | Page | 2 |
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