Attachment_10_-_Past_Performance_Information_Sheet.docx

Attachment 10 Past Performance Information Sheet

Name of Contractor: Click here to enter text.

Solicitation Number: HSCG23-17-R-P1C000 – Multidiscipline Healthcare throughout the United States.

Closing Date: 2:00 PM Eastern Standard Time 20 March 2017

The contractor shall complete Section I of the Past Performance Information Sheet and submit to the customer Point of Contact (POC) for completion of Section II. The customer POC shall submit the entire completed Past Performance Information Sheet (Sections I and II) directly to the Contracting Officer via email to Deborah.Culver@uscg.mil no later than the closing date and time of the solicitation. The Government will not consider Past Performance Information Sheets submitted after the closing date and time of the solicitation.

Section I –Completed by Contractor A. Contract Number: Click here to enter text.

B. Contract Amount: Click here to enter text.

C. Description of Services:

If this is not the offeror’s contract describe how this past performance is pertinent. (See Sections L.2.2.2, L.2.2.3, L.2.2.4 and L.2.2.5 of the solicitation) Click here to enter text.

Section II Completed by Customer - Submit entire completed Past Performance Information Sheet (Sections I and II) not later than the 2:00 local time 13 September 2016 via email to: Deborah.Culver@uscg.mil

Please complete for all Medical and Clinical Dental Services ONLY provided with in the last 3 years (3 August 2013 through 2 August 2016) for the contract(s) listed on page 1, Section I, A.

Please provide as much detail as possible, specifically referencing labor categories in your comments.

1) Were all positions filled at the start of the contract? Click here to enter text.

2) Did the contractor submit complete and timely qualification/credential packages? Click here to enter text.

3) Were candidates qualified in accordance with the contract? Click here to enter text.

4) Describe any instances that resulted in the removal of workers. Click here to enter text.

5) Describe any documented deficiencies with the contractor’s performance? Click here to enter text.

a. Describe the effectiveness and timeliness of corrective actions taken by the contractor for any deficiencies. Click here to enter text.

6) What was the overall percentage of the shifts that were filled (fill rate)? Click here to enter text.

a. Was the fill rate in accordance with the contract? Choose an item.

7) Were there any long-term vacancies? Choose an item.

a. If so, how long and how many? Click here to enter text.

b. How many positions were terminated due to a long term vacancy? Click here to enter text.

8) How much worker turnover occurred? Click here to enter text.

a. When turnover occurred were timely replacements provided? Choose an item.

9) Describe the contractor’s greatest strength. Click here to enter text.

10) Describe the contractor’s responsiveness? Click here to enter text.

11) How would you describe the overall performance by the contractor? Choose an item.

12) Would you consider working with the contractor again in the future? Choose an item.

a. Why or why not? Click here to enter text.

13) Additional remarks: Click here to enter text.

Individual completing the survey:

Name ____________________________ Title ___________________ Phone __________________________

____________________________________ Click here to enter a date.

Signature

Alternate Point of Contact:

Name ____________________________ Title ___________________ Phone __________________________