Attachment No 10 - Revised past Performance Questionnaire.pdf

Attachment No 10 Past Performance Questionnaire

Revised 10-06-2010

Past Performance Questionnaire

(To be completed by Contractor’s client/customer)

INSTRUCTIONS:

The questions contained below are to be used to evaluate the performance record of a contractor submitting a proposal in response to the RFP issued by the National Institutes of Health for Specialized Housekeeping Services.

Please complete this performance questionnaire and return to:

Mr. Brian Lind, Contract Specialist National Institutes of Health, Clinical Center, Office of Purchasing and Contracts, 6707 Democracy Blvd., Suite 106, Room F Bethesda, Maryland 20892-5480

Before October 25, 2010, fax is acceptable at (301) 402.0749. Your responses to this questionnaire will be considered confidential, except as explained below. Responses returned by contractors will not be used in the performance evaluation. For the purposes of this survey, “Contractor” refers to the specific contractor that requested you to provide this information to the Government.

For each of the following areas, rate the performance of the Contractor as (5) Outstanding; (4) Excellent;

(3) Good; (2) Fair; (1) Poor; (0) Unsatisfactory; or (N/A) Not Applicable. Indicate your rating by circling the appropriate number.

Include a narrative explanation whenever you feel that it is appropriate, but as a minimum when a rating of “Unsatisfactory” is given. Please note that if an “Unsatisfactory” rating is given, the contractor will be made aware of it and will be asked to comment.

This survey pertains to: Solicitation Number NIHCL2010076

Specialized Housekeeping Services

Company: (Company requesting survey completion)

Type of Contract and Length of Contract:

Years of Service at Your Facility:

Department/Component:

Contract Number:

Date of Survey:

Name of Person Completing Survey:

Your Company/Agency:

Your Role in the Company/Agency:

Contract Value (including options if applicable): $

Performance Period: (including option periods)

General description of products/services required under the contract:

RATINGS

Please answer each of the following questions with a rating that is based on objective measurable performance indicators to the maximum extent possible. Commentary to support rating shall be noted on page 4.

Assign each area a rating of 0 (Unsatisfactory), 1 (Poor), 2 (Fair), 3 (Good), 4 (Excellent), or 5 (Outstanding). Use the attached Rating Guidelines as guidance in making these evaluations. Circle the appropriate rating. If you do not have enough personal knowledge or feedback from internal customers who directly received products and services from the contractor to make a determination on any of the performance criteria below, please circle "N/A" (not applicable/no opinion).

QUALITY OF SERVICE

1. Compliance with contract requirements

0 1 2 3 4 5 N/A

2. Accuracy of reports 0 1 2 3 4 5 N/A

3. Effectiveness of personnel 0 1 2 3 4 5 N/A

4. Technical Excellence 0 1 2 3 4 5 N/A

QUALITY ASSURANCE PROGRAM

1. Did the firm utilize a computer based Quality Assurance Program

0 1 2 3 4 5 N/A

2. Was the program tailored to your facility?

0 1 2 3 4 5 N/A

3. Generated monthly reports 0 1 2 3 4 5 N/A

4. Were the QA scores used as part of an incentive program?

0 1 2 3 4 5 N/A

5. Did the firm have routine meetings (weekly, bi-weekly, monthly, etc.) with the facility to review QA results?

TIMELINESS OF DELIVERY

1. Met interim milestones

0 1 2 3 4 5 N/A

2. Reliability

0 1 2 3 4 5 N/A

3. Responsive to technical direction

0 1 2 3 4 5 N/A

4. Completed on time including wrap-up and contract administration

0 1 2 3 4 5 N/A

5. Met delivery schedules

0 1 2 3 4 5 N/A

6. Timely, current & complete reporting, tracking & documentation

BUSINESS RELATIONS

1. Effective management

0 1 2 3 4 5 N/A

2. Reasonable/cooperative behavior

0 1 2 3 4 5 N/A

3. Responsive to requirements

0 1 2 3 4 5 N/A

4. Notification of problems

0 1 2 3 4 5 N/A

5. Flexibility

0 1 2 3 4 5 N/A

6. Pro-active vs. reactive

(Proactive) (Reactive)

CUSTOMER SATISFACTION

1. The contractor is committed to customer satisfaction.

Yes No (circle one)

2. Would you recommend selection of this firm again?

Yes No (circle one)

GENERAL

1. What year was your last Joint Commission Survey (Healthcare Facilities)

2. What was the score received by the Housekeeping Department?

3. Were there any deficiencies or recommendations for the Housekeeping Department?

Yes No (circle one) If yes please give details as to the deficiencies or recommendations.

4. Does your facility have research capabilities?

5. Are there any issues pertaining to Infection Control and the firm?

ADDITIONAL COMMENTS (attach page for comments)

National Institutes of Health, Clinical Center Past Performance Questionnaire

Rating Guidelines

QUALITY OF

PRODUCT OR

SERVICE

TIMELINESS OF

PERFORMANCE

BUSINESS

RELATIONS

0-Unsatisfactory

Contractor is not in compliance and is jeopardizing achievement of contract objectives

Contractor delays are jeopardizing performance of contract objectives

Response to inquiries, technical/ service/ administrative issues is not effective

1-Poor

Major problems have been encountered

Contractor is having major difficulty meeting milestones and delivery schedule service/ administrative issues is marginally effective

2-Fair

Some problems have been encountered

Contractor is having some problems meeting milestones service/ administrative issues is somewhat effective

3-Good

Minor inefficiencies/ errors have been identified

Contractor is usually effective in meeting milestones and delivery schedule service/ administrative issues is usually effective

4-Excellent

Contractor is in compliance with contract requirements and/or delivers quality products/services

Contractor is effective in meeting milestones service/ administrative issues is effective

Signature:______________________Organization:_________________

Title:__________________________Date:_________________________