Attachment_3_Past_Performance_Questionnaire_-_Medical_Supplies.pdf

Attachment 3

U.S. Customs and Border Protection Medical Supplies HSBP10-14-R-0046

PAST PERFORMANCE QUESTIONNAIRE

PART ONE: INSTRUCTIONS

The company who has provided you with this form is proposing on a Department of Homeland Security solicitation to provide Medical Supplies. Past Performance is an important part of the evaluation criteria for this acquisition, so your input is very important. Your response on this form shall be sent directly to Amanda Freeman, the DHS CBP Contract Specialist. Do not send back to the requesting company or individual. Please provide an honest assessment and return the questionnaire by fax or email to the address shown below: If you have questions, please contact Amanda Freeman at (202) 344-1904. Facsimile: (202) 344-1254 – email:

amanda.freeman@cbp.dhs.gov.

PART TWO: GENERAL INFORMATION

1. CONTRACTOR’S NAME AND ADDRESS 2. CUSTOMER ORGANIZATION

3. CONTRACT NUMBER: 2a. EVALUATOR

4. CONTRACT VALUE : NAME:

$ TITLE:

PHONE NO:

5. CONTRACT AWARD DATE: 6. CONTRACT COMPLETION DATE:

7. CONTRACT TYPE: 8. COMPLEXITY OF WORK (Circle One Response):

mailto:joshua.bedregal@cbp.dhs.gov

DIFFICULT ROUTINE

PART TWO: GENERAL INFORMATION CONTINUED

9. BRIEF DESCRIPTION OF YOUR CONTRACT REQUIREMENTS:

PART THREE: OFFEROR PERFORMANCE RATING

On the following pages, please summarize the contractor’s performance in each rating factors. Each factor has a set of subfactors with four possible adjectival ratings. Determine the adjectival rating that most nearly represents your experience with this contractor and indicate your assessment by placing an “X” under the appropriate heading. Offeror performance factors are:

A. QUALITY OF PRODUCTS AND SERVICES

B. TIMELINESS OF PERFORMANCE

C. COST EFFECTIVENESS

Adjectival ratings are defined below and should be used as a reference in assessing performance:

EXCEPTIONAL

The contractor’s performance met all contract requirements and exceeded many to the customer’s benefit. The contractor’s performance has resulted in a high level of efficiency, productivity and quality. Very little risk anticipated with performance or lack of customer satisfaction.

SATISFACTORY

The contractor’s performance met the customer’s expectations or contract requirements. Some potential risk and lack or customer satisfaction is anticipated based upon the contractor’s past performance

MARGINAL

Performance did not meet some contractual requirements. There were problems, some of a serious nature, for which the contractor’s corrective actions were only marginally effective.

NEUTRAL

No relevant past performance record is available for evaluation.

UNSATISFACTORY

Performance did not meet most (or all) contractual requirements.

There were serious problems and the contractor’s corrective actions were ineffective

A QUALITY OF PRODUCTS

AND SERVICES

Exceptional Satisfactory Marginal Unsatisfactory Neutral

1 Did the contractor provide high quality goods/products that met customer requirements and standards?

2 Did the contractor provide quality reports and documentation (i.e., accurate, current and complete)?

3 Did the contractor provide a high level of customer service to include responsiveness and business-like concern for the customer?

4 Did the contractor fulfill and deliver orders in conformance with the customer’s requirements?

B TIMELINESS OF

PERFORMANCE

Exceptional Satisfactory Marginal Unsatisfactory Neutral

1 Did the contractor adhere to contract delivery schedules in the following areas:

(a) performance of services?

(b) delivery of goods?

(c) delivery of reports or other documentation?

C COST EFFECTIVENESS

Exceptional Satisfactory Marginal Unsatisfactory Neutral

1 To what extent did the contractor provide goods/products in a cost effective manner and consistent with your pricing agreement?

PART THREE: OFFEROR PERFORMANCE RATING CONTINUED

1. Has this contract been partially or completely terminated for default or convenience?

YES Default Convenience

NO

If yes, please explain (e.g. inability to meet cost, performance, or delivery schedules - also include contract number, name, address, and phone number of Terminating Contracting Officer - TCO).

2. What was the contractor’s greatest strength in the performance of the contract?

3. What was the contractor’s greatest weakness in the performance of the contract?

4. Would you award another contract to this contractor?

YES No

COMMENTS:

PART FOUR: EVALUATOR’S CERTIFICATION

I HEREBY CERTIFY THAT THE INFORMATION IN THIS FORM IS ACCURATE AND

COMPLETE TO THE BEST OF MY KNOWLEDGE.

PRINT NAME OF EVALUATOR

SIGNATURE OF EVALUATOR

TITLE OF EVALUATOR