38_Section_L _Exhibit_L-2_Past_Performance_Questionnaire.doc

Exhibit L-2 Past Performance Questionnaire

TRICARE Quality Monitoring Contract (TQMC)

PAST PERFORMANCE QUESTIONNAIRE

SOURCE SELECTION INFORMATION

Please complete this questionnaire and return it directly to (Offeror’s name and address).

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 pursuant to FAR 2.101 and 3.104.

Contractor/Subcontractor Name:

Customer/Account Name:

Customer/Account Address:

Primary Point of Contact Name/Title:

Primary Point of Contact Phone/Fax Numbers:

Alternate Point of Contact Name/Title:

Alternate Point of Contact Phone/Fax Numbers:

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

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

Total Contract Value:

Total Contract Value Exercised to Date (Total dollar value exercised to date if offeror was the prime contractor. If the offeror performed as a first-tier subcontractor on the contract, state the total contract dollar value and identify the dollar value awarded to the offeror as subcontractor.):

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/processing 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. Additional questions 8-10 follow. Please use the space following each question to provide additional detailed 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.

Past Performance Quality Ratings

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.

Exceptional.

Very Good.

Satisfactory.

Marginal.

Unsatisfactory.

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.

Exceptional.

Very Good.

Satisfactory.

Marginal.

Unsatisfactory.

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.

Exceptional.

Very Good.

Satisfactory.

Marginal.

Unsatisfactory.

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.

Exceptional.

Very Good.

Satisfactory.

Marginal.

Unsatisfactory.

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.

Exceptional.

Very Good.

Satisfactory.

Marginal.

Unsatisfactory.

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.

Exceptional.

Very Good.

Satisfactory.

Marginal.

Unsatisfactory.

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 clinical measure 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 connectivity with critical information systems, websites, etc., in a timely manner? Please explain if there were any problems and how they were resolved.

3) If applicable, did the contractor accomplish the security certifications of the information systems within the timelines? 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:

TQMC HT9402-15-R-0005, Section L, Exhibit L-2