ATTACHMENT_6_PAST_PERFORMANCE_QUESTIONNAIRE.docx

ATTACHMENT 6

PAST PERFORMANCE QUESTIONNAIRE

When filled in, this document is source selection sensitive information IAW FAR 2.101 and 3.104

Offeror: Complete SECTION 1, and send a questionnaire to the primary customer point of contact (POC) listed on the Past Performance Information Sheet who is identified as the most familiar with the performance of the effort on the contract. If you have any problems getting a signed questionnaire from the Government, please contact Jennifer Felt at (210) 221-6231.

Primary Customer POC: Please complete SECTIONS 2-5. Handwritten responses are sufficient. If you need more space, please attach one additional page. All questionnaires need to be returned to the originator who sent the form to you NLT (Offeror will enter date). If you have any questions about sending this form to the Offeror, please contact Jennifer Felt at DHA (210) 221-6231.

SECTION 1: CONTRACTOR IDENTIFICATION

SOLICITATION NUMBER: ______________________________

Proposal Volume III Tab #:

A. Contractor

Other (specify) ______________________

B.1 If Performed as a Subcontractor/Teaming Partner list Prime Contractor:

C. Contract Number

D. Task Order Number (if applicable)

E. Contract Type

No

G. Period of Performance

H. Contract/Task Order Value ($) (Including all options both exercised and not exercised)

SECTION 2: AGENCY OR ORGANIZATION IDENTIFICATION

A. Agency or Organization Name:

B. Location of services:

C. Description of services provided by the Offeror or proposed subcontractor:

D. Agency/Organization for this contract or task order (choose as many as apply):

|_| Department of Defense Medical (Air Force, Army, Navy, DHA/TMA, OSD/HA) |_| Other Federal Agency (Provide agency name if different from above) |_| Commercial Medical (e.g., hospital or health operations) |_| Non-medical

E. Clinical service categories provided under this contract or task order (choose as many as apply):

|_| Ancillary Services – (e.g., audiologists, dietitians, mid-level providers, pharmacists) |_| Dental Services – (e.g., dentistry and dental support) |_| Nursing Services – (e.g., registered and advanced practice nurses, practical and vocational nurses) |_| Physicians – (e.g., primary care and specialty practitioners) |_| Other: Please explain below:

SECTION 3: EVALUATOR IDENTIFICATION

A. Evaluator’s Name

B. Evaluator’s Title

C. Evaluator’s Phone/Fax Number

D. Evaluator’s Mailing Address

E. Number of years evaluator worked on contract

SECTION 4: EVALUATION

Please confirm that your evaluation is consistent with the service provided in Section 2, Paragraph C, Description of Services. Indicate the Contractor’s performance by circling the level of performance using the scale provided below and to the right of each question. This scale is defined as follows:

S

SATISFACTORY – The Contractor’s performance meets contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the Contractor appear or were resolved satisfactorily.

M

MARGINAL – Performance does not meet some contractual requirements. The contractual performance reflects a serious problem for which the Contractor has not yet identified corrective actions or the Contractor’s proposed actions appear only marginally effective or were not fully implemented.

U

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

N

NOT APPLICABLE – Unable to provide a score.

The Prime Contractor:

For the overall rating, if you indicated E (Exceptional) or V (Very Good), describe specifically how the Contractor exceeded contract requirements to the Government’s benefit. If you indicated M (Marginal) or U (Unsatisfactory) describe specifically how the Contractor did not meet requirements. Use additional sheets if necessary.

Government Contracts Only: Has/was this contract been partially or completely terminated for default, convenience, or are there any pending terminations?

Yes

No

Default

Convenience

Pending Terminations

If yes, please explain below (e.g., inability to meet cost, performance, or delivery schedules, etc.).

SECTION 5: NARRATIVE SUMMARY

What were the Contractor’s most positive aspects in the performance of the contract?

What were the Contractor’s most negative aspects (if any) in the performance of the contract?

Would you have any reservations about soliciting this Contractor in the future?

Evaluator’s Signature Date:

Please sign and email completed questionnaire to the originator for submission as part of their past performance volume. Thank you for your prompt response and assistance!