J-19a Past Performance Questionnaire v1.docx

Attachment J-19a Past Performance Questionnaire

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.

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 _________________

Annual Contract Value:

Number of Beneficiaries/Customers Served:

Annual Number of Claims Processed (if applicable):

INSTRUCTIONS: Please provide your responses to the questions below. Questions 1-4 pertain to the contractor’s performance in relation to the stated terms of the contract (contract requirements, timeliness/processing standards, provider network access). Questions 5 – 8 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 9-11 follow. Please use the space following each question to provide additional detailed information. Detailed information is critical to the evaluation of the past performance.

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 full 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 the standards 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 the standards 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 full 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. Does or did the stated contract have provider network access 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 provider network access standards and exceeded some. Where the standards 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 provider network access standards and exceeded some. Where the standards 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 provider network access 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 provider network access 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 full implemented.

(__) Failed to meet most provider network access 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 provider network access standards were beneficial to the customer; what were some of the problems and the corrective actions taken, etc.):

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

If no, explain why not:

5. 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.

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

6. 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.

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

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 ability to satisfy customers and summarize some examples below.

Comments (e.g., summarize examples of customer satisfaction):

8. 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.

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

9. 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 enrollee 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.

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.

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

(__) Yes (__) No

If yes, give a brief summary of the exceptional areas of performance that makes you want to do business with them in the future. If no, explain why not.

11. Additional Comments:

Questionnaire completed by:

Name:

Title:

Signature: (either electronically or scan original signature)

Date Questionnaire Completed:

ADDP3

HT9402-20-R-0001 Attachment J-19a Page 1 of 7 SOURCE SELECTION INFORMATION See FAR 2.101 & 3.104