Past_Performance_Contract_Reference_Data.docx
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- Pre-employment and Employee Medical Services
- Solicitation number
- HSBP1013R0033
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The attached Past Performance Survey document replaces attachment 24.
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PAST PERFORMANCE CONTRACT REFERENCE DATA
Program or Task Order Title
Customer Name
| Customer Address |
| Street |
City/State
Zip
Tel.
Fax
| Contract Points of Contact |
| Contractual: |
Technical:
Name
Name
Title
Title
Organization
Organization
Address
Address
Tel.
Tel.
Fax
Fax
Contract Type
Contract Number
Task Order # if Applicable
Description of Services
Task Order Technical Point of Contact Name
Title
Organization
Address
Tel.
Fax
| Period of Performance |
| Project Start Date |
Original Completion Date
Estimated/Actual Completion Date
Explanation of Delay if Applicable
| Contract Value |
| Original Value |
Current Value
Estimated/Actual Completion Date
Explanation of Cost Growth
| Small Business Subcontracting |
| Levels achieved against subcontracting plan goals (if applicable) and as a percentage of contract value |
Note: This form will be included in the Request for Proposals to facilitate the past performance evaluation.
APPENDIX D: PAST PERFORMANCE RELEVANT EXPERIENCE FORM
Company Name: ____________________________________
Referenced Contract: ____________________________________ Instructions: Offerors will complete the following worksheet for each contract provided as a reference.
| ITEM |
| DESCRIPTION |
| YES/NO |
| QUANTITY |
| 1 |
| Did you serve as the prime contractor (rather than a subcontractor) for the referenced effort? |
| 2 |
| What were the total contract dollar value and the term of the contract, including all option periods? |
_____years
| 3 |
| Did you perform and review medical examinations under this effort? |
| 4 |
| Did you perform urine specimen collections under this effort? |
| 5 |
| Did you handle sensitive personally identifiable information under this effort? |
| 6 |
| Did you perform scheduling services for the client? |
| 7 |
| Did you interact with third parties including other prime contractors? |
| 8 |
| Did you interact with the client on a daily basis? |
| 9 |
| Did you utilize an automated data system for tracking progress and reporting data to the client? |
| 10 |
| Did you provide reports to the client? |
| 11 |
| Did you provide feedback and suggestions to the client on ways to improve processes? |
| 12 |
| Did you assist the client in document management and archiving? |
| 13 |
| Did you develop budget reports, to include open obligations and expenditure data? |
| 14 |
| Did you ever default on the referenced effort? |
| 15 |
| Do you have documented negative performance records for the referenced effort? |
| 16 |
| Did you maintain subcontracts in order to perform the services required by this contract? |
| 17 |
| Did you perform quality assurance checks on your subcontractors to ensure they were properly trained/certified/qualified to perform the tasks under this effort? |
| 18 |
| Please respond to this question only if you served as the prime contractor for this contract. What percent of the dollar value of the total contract was proposed for each category and what percent was actually awarded to subcontractors in each category? |
| % of $ |
Planned % of $ Actually Awarded
a. Small Business
b. Small Disadvantages Business
c. Women-owned Small Business
d. HUB Zone Small Business
e. Service-disabled Veteran-owned Small Business
f. 8(a) Business
Note: This form will be included in the Request for Proposals to facilitate the past performance evaluation.
File details come from the government source that posted it. Updated .