Attachment_4_Past_Performance.pdf

Attachment 4 RFP: Consumable Medical Supplies (CMS) - Past Performance Questionnaire (PPQ)

A. CERTIFICATION

By law, the Government will not disclose the names of individuals providing reference information during discussions with the contractor identified in Block 1 below.

Block 1. Contractor Name:

Block 2. Contractor phone number and address:

Block 3. Contract Name and Number: |

I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS QUESTIONNAIRE IS

ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

Evaluator’s Printed Name Title

Evaluator’s Mailing Address (Agency, Bldg/Room, Street, City, State, Zip)

Evaluator’s Signature Date Phone Fax

B. INSTRUCTIONS

PAST PERFORMANCE QUESTIONNAIRE

The Department of Homeland Security (DHS), FEMA, recently released a

Request for Proposal: for Consumable Medical Supply. Offerors were asked to provide information on contracts similar in nature, size and complexity to the present requirement on which they had performed in the past. An offeror has submitted this to you as a reference for past performance. (See blocks 1 to 3 below).

We need your opinion on how well the contractor performed on your contract(s). Please fill out the attached questionnaire and send it electronically to the Contracting Officer, Carolyn Knight at Isaac.Chapple@fema.dhs.gov. To be considered, this form must be filled out and received by the contracting officer no later than the closing date and time listed in the request for proposal. DHS/FEMA may contact you to clarify or verify any information provided. For purposes of confidentiality, only send this completed form to the FEMA contracting officer.

Your input will be confidential. Please note your comments will be used to form the basis for evaluation of this offeror. Thank you in advance for your assistance. If you have any questions please contact the Contracting Officer at

Two forms are provided to document your opinion: 1) Performance Rating Form;

and 2) Supplemental Comment Form. Please fill out both forms in accordance with the instructions provided on each. Please use the following standards in arriving at your rating: 1) Acceptable - the contractor’s overall performance was acceptable but with some minor exceptions; 2) Unacceptable – the contractor’s overall performance was unacceptable or 3) Neutral: Offeror has no relevant past performance.

mailto:Isaac.Chapple@fema.dhs.gov

Performance Element Neutral Acceptable Unacceptable

1. QUALITY OF SERVICES: The contractor provided high quality of service.

2. CUSTOMER SATISFACTION:

The contractor exhibited a commitment to customer satisfaction and achieved customer satisfaction.

3. TIMELINESS OF

PERFORMANCE AND

COMPLETION OF THE

CONTRACT: The contractor planned and proposed realistic schedules, successfully monitored performance and completed work on time.

Yes No

1. Given the choice would you do business with this contractor again?

Supplemental Comment Form

Please provide any additional comments regarding your performance element ratings in the appropriate spaces below. Please add additional pages as necessary.

Performance Element #1, Quality of Services:

Performance Element #2, Customer Satisfaction:

Performance Element #3, Timeliness of Performance and Completion of the Contract:

Question #1:

Given the choice would you do business with this contractor again?