ATTACH C_PAST PERFORMANCE QUESTIONNAIRE.pdf

RFP No. HSFEHQ-12-R-0001

ATTACHMENT C

PAST PERFORMANCE QUESTIONNAIRE

PLEASE EMAIL THIS PACKAGE TO: Michelle Calhoun, CONTRACTING OFFICER AT michelle.calhoun@fema.dhs.gov by 12:00 PM on the date of 03/05/2012

MUST INCLUDE IN EMAIL SUBJECT LINE:

PAST PERFORMANCE, RFP Number HSFEHQ-12-R-0001

PERSONAL ASSISTANCE SERVICES (PAS)

NAME OF CONTRACTOR

The Federal Emergency Management Agency recently released a solicitation for a Contractor(s) to provide support services for a Personal Assistance Services (PAS) Contract. Offerors were asked to provide information on contracts, similar in size and complexity to the procurement, on which they had performed in the past. An Offeror has submitted you as a reference for past performance.

We need your opinion on how well the Contractor performed on this contract (Complete blocks 1 & 2 below).

Please fill out the attached questionnaire and send it to Michelle Calhoun. FEMA may contact you to clarify and/or verify any information provided.

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 Michelle Calhoun by email at Michelle.Calhoun@fema.dhs.gov.

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 PLEASE ENTER NAME OF CONTRACTOR Block 2. Contract Name/Identifier PLEASE ENTER CONTRACT 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/Role (e.g. Program Manager, Contracting Officer)

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

Evaluator’s Signature Date Phone Fax

INSTRUCTIONS

Two forms are provided to document your opinion: 1) Performance Rating Form; and 2) Supplemental Comment Form. Please fill out each form in accordance with the instructions provided on each. Please use the following standards in arriving at your rating:

Outstanding – Contractor exceeded client expectations and requirements Satisfactory – Contractor met customer expectations and requirements Unsatisfactory – Contractor was either marginal or did not meet customer expectations and requirements Other - The element is not applicable, no data has been obtained, or additional comments are provided

Please mark the column to the right of each element that most appropriately reflects your experience with this contractor. Please use the additional page to discuss more fully any of the elements. Whenever you mark “Other”, please provide comments.

Performance Element Outstanding Satisfactory Unsatisfactory Other/Comments

1. TIMELINESS OF PERFORMANCE:

The contractor planned and proposed realistic schedules, successfully monitored performance and completed work on time. The Contractor assigned, in a timely manner, the proper amount and type of personnel to successfully accomplish the specified effort.

2. CUSTOMER SATISFACTION: The contractor exhibited a commitment to customer satisfaction by providing a high level of quality of care and by consistently exhibiting a professional approach to client service.

3. RESPONSIVENESS AND

ATTENTIVENESS: The contractor exhibited reasonable and cooperative behavior in quickly remedying any performance related issues with the client.

4. COST CONTROL: The contractor successfully planned and proposed realistic costs and monitored performance, and consistently operated at or below budget, such as travel related expenses.

For #5 and #6 please answer "Yes" or "No" as appropriate YES NO

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

6. Did either you or the contractor have to resort to litigation to resolve problems?

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 - Timeliness of Performance:

Performance Element #2 - Customer Satisfaction:

Performance Element #3 - Responsiveness and Attentiveness:

Performance Element #4 - Cost Control:

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

Did either you or the contractor have to resort to litigation to resolve problems?

Additional Comments: