17_Exhibit_L-5_Past_Performance_Questionnaire_4-2-13.doc

Exhibit L-5 Past Performance Questionnaire

TDEFIC PAST PERFORMANCE QUESTIONNAIRE

SOURCE SELECTION INFORMATION

Responses will be treated as confidential and will be used only by source selection officials in evaluating the offeror’s submitted documents for the contract.

Contractor/Subcontractor Name*:

* To facilitate proposal evaluation, the offeror or its first-tier subcontractor/teaming partner shall CLEARLY state the offeror’s name under which the proposal is submitted to the Government. The past performance questionnaire will not be considered if the Government cannot determine whose past performance or the offeror team to which the past performance belongs.

Customer/Account Name:

Customer/Account Address:

Primary Point of Contact Name/Title:

Primary Point of Contact Phone/Fax Numbers:

Alternate Point of Contract Name/Title:

Alternate Point of Contact Phone/Fax Numbers:

Period of Performance (month/year): From _________________ to _________________

Annual Contract Value:

Number of Beneficiaries/Customers Served:

Annual Number of Claims Processed (if applicable):

Contract Summary (to include type and scope of services provided):

INSTRUCTIONS: Please provide your responses to the questions below. Questions 1-3 pertain to the contractor’s performance in relation to the stated terms of the contract (contract requirements, timeliness, standards, etc.). Questions 4-7 pertain to the manner in which the work was performed (responsiveness, attitude, staff knowledge/skills/abilities, etc.), regardless of how the contractor performed in relation to the terms of the contract. Please use the space following each question to provide additional details or information.

If there are any questions regarding the responses provided, source selection officials will attempt to contact the Primary or Alternate Points of Contact identified on Page 1.

1. In regard to only the stated contract requirements (not the manner in which the work was performed), please mark an “X” next to the response that best describes the contractor’s performance and summarize some examples below.

Met all of the contract requirements and exceeded some. Where requirements were exceeded, the result was a significant benefit to the customer. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

Met all of the contract requirements and exceeded some. Where requirements were exceeded, the result was nominally beneficial to the customer. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

Met all of the contract requirements. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

Met most of the contract requirements. Contractual performance reflects problem(s) for which the contractor did not perform (or has not yet performed) corrective actions, or corrective actions were only marginally effective, or not fully implemented.

Failed to meet most contract requirements. Contractual performance contains serious problems for which the contractor’s corrective actions, if any, were incorrect or ineffective.

Not applicable (explain why)

Comments (e.g., summarize some examples of the performance indicated above; explain why/how exceeded requirements were beneficial to the customer; what were some of the problems and the corrective actions taken, etc.):

2. Does or did the stated contract have timeliness/processing standards? If so, please mark an “X” next to the response that best describes the contractor’s performance and summarize some examples below.

Met all of the timeliness/processing standards and exceeded some. Where requirements were exceeded, the result was a significant benefit to the customer. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

Met all of the timeliness/processing standards and exceeded some. Where requirements were exceeded, the result was nominally beneficial to the customer. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

Met all of the timeliness/processing standards. Contractual performance was accomplished with few, if any, minor problems. Any corrective actions taken by the contractor were prompt and effective.

Met most of the timeliness/processing standards. Contractual performance reflects problem(s) for which the contractor did not perform (or has not yet performed) corrective actions, or corrective actions were only marginally effective, or not fully implemented.

Failed to meet most timeliness/processing standards. Contractual performance contains serious problems for which the contractor’s corrective actions, if any, were incorrect or ineffective.

Not applicable (explain why)

Comments (e.g., summarize some examples of the performance indicated above; explain why/how exceeded timeliness/processing standards were beneficial to the customer; what were some of the problems and the corrective actions taken, etc.):

3. Did the contractor deliver at the agreed-to price? (__) Yes (__) No

If no, explain why not:

4. In regard to the manner in which the work was performed, please mark an “X” next to the response that best describes the attitude of the contractor’s staff and summarize some examples below.

Exceeded expectations

Met expectations all of the time Met expectations most of the time

Met expectations some of the time

Did not meet expectations

Not applicable (explain why not)

Comments (e.g., summarize examples of the staff’s attitude):

5. In regard to the manner in which the work was performed, please mark an “X” next to the response that best describes the knowledge, skills and abilities of the contractor’s staff and summarize some examples below.

Exceeded expectations

Met expectations all of the time

Met expectations most of the time

Met expectations some of the time

Did not meet expectations

Not applicable (explain why not)

Comments (e.g., summarize examples of the staff’s knowledge, skills and abilities):

6. In regard to the manner in which the work was performed, please mark an “X” next to the response that best describes the contractor’s ability to satisfy customers and summarize some examples below.

Exceeded expectations

Met expectations all of the time

Met expectations most of the time

Met expectations some of the time

Did not meet expectations

Not applicable (explain why not) Comments (e.g., summarize examples of customer satisfaction):

7. In regard to the manner in which the work was performed, please mark an “X” next to the response that best describes the contractor’s responsiveness to resolving problems within the scope of the contract and summarize some examples below.

Exceeded expectations

Met expectations all of the time

Met expectations most of the time

Met expectations some of the time

Did not meet expectations

Not applicable (explain why not)

Comments (e.g., summarize examples of how the contractor responded to resolving problems):

8. In regard to the transition-in phase of this contract please answer the following questions:

1) If applicable, did the contractor accomplish the transition of large data bases such as file layouts/claims history files from the predecessor in accordance with the timelines? Please explain if there were any problems and how they were resolved.

2) Did the contractor accomplish the connectivity of the information systems to finance centers, customer websites, etc., in a timely manner? Please explain if there were any problems and how they were resolved.

9. If you had an opportunity to do so, would you do business with this contractor in the future?

(__) Yes (__) No

If no, explain why not:

10. Additional Comments:

Questionnaire completed by:

Name:

Title:

Signature:

Date Questionnaire Completed:

SOURCE SELECTION INFORMATION WHEN COMPLETED, SEE FAR 2.101 & 3.104

TDEFIC, HT9402-12-R-0005, Exhibit L-5 Past Performance Questionnaire