Attachment 3 - Past Performance Questionnaire.PDF

PAST PERFORMANCE QUESTIONNAIRE

To the Offeror’s Reference:

The Defense Health Agency's (DHA) National Capital Region-Contracting Division (NCR-CD) is conducting an acquisition to obtain to perform at Medical Treatment Facilities within the NCR. The Offeror has identified you/r office 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 Offeror’s past performance. A typed (preferred) or handwritten response is sufficient. If you need more space than that provided, please attach additional pages. After completion please return to the assigned Contract Specialist tamia.m.mccoy.civ@mail.mil.

Thank you for your assistance in this source selection. If you have any questions, please email at:

tamia.m.mccoy.civ@mail.mil and faatalivale.m.teo-lewis.civ@mail.mil.

A. EVALUATED CONTRACTOR’S INFORMATION:

Company/Organization Name being evaluated:

Cage Code:

Point of Contact (POC):

Title of POC:

Address:

Telephone Number:

Email address:

B. CONTRACT INFORMATION:

Contract Title/Description:

Contract Number:

Task Order Number (if Applicable):

Status (i.e. On-going, complete):

Contract Amount: (Total amount of base period of performance plus any option period(s) exercised to date)

Type of Contract (e.g. FFP, Cost, etc.):

Performance Period being evaluated:

Place of Performance:

Labor Categories

Number of workers per labor category

Was work with a: Commercial_____ Fed Gov’t_____ Local/State Gov’t_____ entity.

C. CONTRACTING OFFICER REPRESENTATIVE INFORMATION:

COR’s Name:

Telephone Number:

Email:

Evaluated Contractor Performed as: Prime Contractor _______ or Sub Contractor ________

D. RATING INFORMATION:

RATING DEFINITION

Exceptional (E)

Performance meets contractual requirements and exceeds many to the Government’s benefit.

The contractual performance of the element or sub-element being evaluated was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Very Good (VG)

Performance meets contractual requirements and exceeds some to the Government’s benefit.

The contractual performance of the element or sub-element being evaluated was accomplished with some minor problems for which corrective actions taken by the contractor was effective.

Satisfactory (S)

Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Marginal (M)

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being evaluated reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Unsatisfactory (U)

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

N/A Not applicable to the subject contract or requirement

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.

Please provide a rationale for your Quality of Services Rating (required for other than satisfactory rating):

Timeliness of Performance/Services

(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.

Please provide a rationale for your Timeliness of Performance/Services Rating (required for other than satisfactory rating):

Business Relations

(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.

Please provide a rationale for your Business Relations Rating (required for other than satisfactory rating):

F. OTHER:

(1) 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.

(2) Based upon the information you provided and using the definitions provided in the evaluation criteria above, please provide your Overall Rating:

Exceptional ______

Very Good ______

Satisfactory ______

Marginal ______

Unsatisfactory ______

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 may result in it in not being evaluated by the

Government):

Signature of Evaluator:

(Digital CAC signature if possible) __________________________________________________________

Typed Name: __________________________________________________________

Title: __________________________________________________________

Date: __________________________________________________________

THANK YOU for your support of the Defense Health Agency's (DHA) National Capital

Region-Contracting Division (NCR-CD)

I appreciate your valuable time and assistance with this important acquisition!