Past_Performance_Questionnaire_Template.pdf

HHSM-500-2017-RFP-171967

Past Performance Questionnaire

Source Selection Information – See FAR 2.101 and 3.104 P a g e | 1

PERFORMANCE QUESTIONNAIRE

Sample Cover Letter

[COMPANY LETTERHEAD (Prime or subcontractor)]

Reference Name, Address and Contact information Date:

SUBJECT: Solicitation HHSM-500-2017-RFP-171967– ESS System Refresh Questionnaire

Dear _________________:

We are currently responding to the Centers for Medicare & Medicaid Services (CMS) Request for Proposal number HHSM-500-2017-RFP-171967 (as a subcontractor to______ (If applicable)). The purpose of this contract is to perform

There is an increased emphasis on past performance in the federal source selection process. The 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 ____________ (to be filled in by Offeror);

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

We sincerely appreciate your cooperation in this matter.

Sincerely, Reference Name

Title

Source Selection Information – See FAR 2.101 and 3.104 P a g e | 2

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: Solicitation HHSM-500-2017-RFP-171967– ESS System Refresh 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.

CMS may engage in exchanges with offerors regarding past performance information submitted to CMS in connection with the subject solicitation. If CMS engages in such exchanges, CMS may share information disclosed in this survey with the Offeror to whom it pertains, as permitted or required by the FAR. Otherwise, CMS will only share information from this survey outside the agency pursuant to a protective order or as otherwise required by law

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 in one of the following manners:

Email PDF (Preferred): patrick.forgione1@cms.hhs.gov lyandra.emmanuel@cms.hhs.gov

Fax Original: (Please call or email for fax number if you want to fax the questionnaire)

Mail Original: Centers for Medicare & Medicaid Services Office of Acquisition and Grants Management

DMITSC

ATTN: Patrick Forgione

Contract Specialist 7500 Security Blvd., Mailstop B3-30-03 Baltimore, MD 21244-1850

Thank you for taking the time to complete the questionnaire.

Sincerely, Lyandra Emmanuel Contracting Officer mailto:patrick.forgione1@cms.hhs.gov mailto:lyandra.emmanuel@cms.hhs.gov

Source Selection Information – See FAR 2.101 and 3.104 P a g e | 3

PAST PERFORMANCE QUESTIONNAIRE

CMS Solicitation No. HHSM-500-2017-RFP-171967

(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.

Source Selection Information – See FAR 2.101 and 3.104 P a g e | 4

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: ________________________