HT0011-14-R-0021-OHI-Attachment_10-Past_Performance_Questionnaire.docx

Solicitation Number: HT0011-14-R-0021 Page 3 of 3 Present and Past Performance Questionnaire

PRESENT AND PERFORMANCE QUESTIONNAIRE

Please complete the following questionnaire and return via email to the attention of:

Defense Health Agency Attn: Ms. Millie Mitchell, Mr. Alim Koroma, Mr. Mercellus Jernigan 7700 Arlington Blvd, Suite 1M411 Falls Church, VA 22042-5101 Millie.Mitchell@dha.mil Alim.koroma@dha.mil Mercellus.Jernigan@dha.mil

This Survey Pertains to: Contractor Name.

Reference Information Table Business Name of Reference & Address

Point of Contact

Phone number

E-mail address

Contract Number

Type

Contract Value

a. Original

b. Value at Completion

c. Reason for any Changes a.)

b.)

c.)

Period of Performance

a. Date Completed/To Be Completed

b. Reason for Any Change a.)

b.)

Brief Description of Effort

Explain any problems and resolutions

Evaluation KEY: Please use the following abbreviations to assign an applicable rating for questions 1 thru 6 below:

Does not meet minimum acceptable standards in one or more areas; remedial action required in one or more areas; deficiencies in one or more areas which adversely affect overall performance.

Meets or slightly exceeds minimum acceptable standards; adequate results; reportable deficiencies with identifiable, but not substantial, effects on overall performance.

Effective performance; fully responsive to contract requirements; reportable deficiencies, but with little identifiable effect on overall performance.

Very effective performance; fully responsive to contract requirements; contract requirements accomplished in a timely, efficient, and economical manner for the most part; only minor deficiencies with minimal effect on overall performance.

Of exceptional merit; exemplary performance in a timely, efficient, and economical manner; very minor (if any) deficiencies with no adverse effect on overall performance.

No record of relevant past performance or past performance information is not available

1. How would you rate the contractor’s compliance with the delivery schedule / performance milestones?

Comments:

P/U|_| S|_| G|_| VG|_| E|_| N|_|

2. How would you rate the contractor’s business practices (e.g. maintaining a positive working relationship, business ethics, timely and effectively resolution of any problems etc.)?

3. How would you rate the contractor’s record of conforming to contract requirements and to standards of good workmanship/quality of the product or service/timeliness of performance/report submission?

4. How would you rate the contractor’s overall compliance with the terms and conditions of your purchase order /contract?

5. How would you rate the contractor’s history of reasonable and cooperative behavior and commitment to customer satisfaction; and generally, the contractor’s business-like concern for the interest of the customer?

6. How would you rate the contractor’s overall performance?

7. Would you purchase services from this contractor again?

|_| YES |_|NO

Please provide any additional comments applicable to the contractor’s past performance

Procurement Sensitive Source Selection Information-See FAR 3.104- For Official Use Only