HT0014-17-R-0002_ATTACHMENT_2__PAST_PERFORMANCE_QUESTIONNAIRE.doc
DOC document 73 KB Posted
- Attached to
- On Call General Pediatric Surgeon Federal contract opportunity
- Solicitation number
- _HT0014-17-R-0002
- Issued by
- Defense Health Agency
About this file
Past Performance Questionnaire
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| HT0014-17-R-00020002.pdf | ||
| HT0014-17-R-00020001.pdf | ||
| Questions_and_Answers_received_in_repsonse_to_52.212-1(e).pdf | ||
| HT0014-17-R-0002.pdf | ||
| Compensation_Matrix.xlsx | XLSX spreadsheet |
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HT0014-17-R-0002 ATTACHMENT # 2 - PAST PERFORMANCE QUESTIONNAIRE
PAST PERFORMANCE SURVEY QUESTIONNAIRE
Hello:
Defense Health Agency’s Contract Operating Division for the National Capital Region is conducting an acquisition to obtain Healthcare Providers at Walter Reed National Military Medical Center, Bethesda, MD. 20889-5600. The offeror has identified you as a reference to validate the offeror’s past performance. Past Performance is an important part of the evaluation criteria for this acquisition, so your input is very important.
Please complete the following questionnaire to assist this office’s evaluation of the contractor’s past performance, and return no later than 5 July 2017 by 12:00 PM (EDT) to: Ed DuChemin (Information Technology Solutions & Consulting, LLC (ITSC) contractor, directly supporting DHA)) at email: edgar.r.duchemin.ctr@mail.mil.
Typed or handwritten responses are sufficient. If you need more space than that provided, please attach additional pages. If contractor has held more than one contract with you, please note that information. Responses will be treated as "source selection sensitive information."
Thank you for your assistance in this source selection. If you have any questions, please email me at: edgar.r.duchemin.ctr@mail.mil or call 703-275-6348.
A. EVALUATED CONTRACTOR’S INFORMATION: (To be completed by the Offeror)
Company/Organization Name being evaluated
Cage Code:
Point of Contact (POC):
Title of POC:
Address:
Telephone Number:
B. CONTRACT INFORMATION: (To be completed by the Offeror)
Contract Title/Description:
Contract Number:
Task Order Number if Applicable
Status (i.e. On-going, complete):
Contract Amount: total amount of base plus any options
Type of Contract
Performance Period being evaluated
Place of Performance:
Total Number of FTEs
Title of Position(s) provided by the Offeror
| Was work with a: |
| Commercial_____ Fed Gov’t_____ Local/State Gov’t_____ entity. |
C. RESPONDENT INFORMATION:
Respondent’s Name:
Respondent’s Title
Company/Organization Name
Address:
Telephone Number:
| Evaluated Contractor Performed as: |
| Prime Contractor _______ or Sub Contractor ________ |
D. RATING INFORMATION:
Choose the number on the scale of 0 to 5 that most accurately describes the Offeror’s performance or situation. If you are unable to rate a question because it was not a requirement or you have no knowledge of the contractor’s performance under the question situation, then you should mark “Not Applicable” and do not include the specific question in the total number of questions answered at the bottom of the applicable section. If the question situation would be considered a part of the required performance under this contract, but the contractor have experience in the area, then mark “0” and include it in the total number answered at the bottom of the applicable section.
| RATING |
| DEFINITION |
| Exceptional = 5 |
| Performance meets contractual requirements and exceeds many requirements to the government’s benefit. (Risk Level: Very Low) |
| Very Good = 4 |
| Performance meets contractual requirements and exceeds some to the government’s benefit. (Risk Level: Low) |
| Satisfactory = 3 |
| Performance meets contractual requirements. (Risk Level: Moderate) |
| Marginal = 2 |
| Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the Contractor has not yet implemented satisfactory corrective action. (Risk Level: High) |
| Unsatisfactory = 1 |
| Performance does not meet contractual requirements recovery is not likely in a timely manner. Contractor’s corrective actions to date are ineffective (Risk Level: Very High) |
| Unknown = 0 |
| The Offeror has little/no relevant past performance upon which to base a meaningful performance risk prediction. (Risk Level: Unknown) |
E. PERFORMANCE EVALUATION QUESTIONS:
Quality of Services
Performance Rating
(1) The Contractor provided quality services that adhered to contract requirements, specifications, and standards of professional conduct.
(2) The Contractor provided quality personnel that met or exceeded the required qualifications.
(3) The Contractor demonstrated an overall effective and quality management effort.
(4) The Contractor maintained an effective on-going Quality Control Plan to provide for monitoring, analyzing, and improving quality contract performance.
Performance Rating Total
Performance Rating Total Divided by total number of questions answered
Overall Rating
Timeliness of Performance/Services
Performance Rating
(1) The Contractor successfully achieved fill-rates established by the contract.
(2) The labor turnover in personnel and other labor categories (to include contracted health care providers) was minimal and did not adversely affect Contractor Performance.
(3) The Contractor consistently demonstrated an ability to quickly recruit HCPs on time to meet the Government’s needs.
(4) The Contractor demonstrated the ability to retain HCPs to support contract/task order requirements so that work schedules would not be disrupted.
(5) The Contractor demonstrated the ability to plan for and provide replacement candidates to include pre-planned absences, unplanned illnesses, or an extended leave of absence.
(6) Credentialing Packages (to include current and complete information) were presented in timely fashion to the applicable facility.
Performance Rating Total
Performance Rating Total Divided by total number of questions answered
Overall Rating
Business Relations
Performance Rating
(1) The Contractor had the ability to respond effectively to contract performance issues.
(2) If applicable, the Contractor acted in accordance with any “Non-Compete Clause” Terms and Conditions of the contract.
(3) The Contractor maintained an open line of communication so that the Contracting Officer’s Representative (COR) was apprised of technical and cost issues.
(4) The Contractor cooperated with the Government in providing flexible, proactive, and effective solutions to critical contract issues.
(5) The Contractor provided proactive and effective management of its subcontractors.
(6) The Contractor was able to resolve customer complaints quickly and effectively.
Performance Rating Total
Performance Rating Total Divided by total number of questions answered
Overall Rating
F. OTHER:
(1) Would you award this firm another contract? ( ) Yes, ( ) No. If you answered “No” provide an explanation. __________________________________________________________________________________________________________________________________________________________________________________
(2) Was a cure notice_____; show cause notice_____; suspension of progress payments, and/or______ termination for default issued to this firm during performance of this contract? If you answered “Yes”, provide an explanation. __________________________________________________________________________________________________________________________________________________________________________________
(3) Based upon the information you provided and using the definitions provided in the evaluation criteria above, please select the overall performance rating for this Contractor.
Exceptional ______
Very Good ______
Satisfactory ______
Marginal ______
Unsatisfactory ______
Unknown ______
COMMENTS: (ALL Unsatisfactory, Marginal, Very Good, or Exceptional Ratings require comments to support the same. Failure to provide comments may render the questionnaire void and will not be evaluated by the Government): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
End of Questionnaire
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