Attachment 2- Past Performance Questionnaire.docx

Attachment 2 – Past Performance Questionnaire Past Performance Questionnaire

The Defense Health Agency (DHA) Healthcare Contracting Division Southeast (HCD-Southeast) is conducting an acquisition for the services noted below. The offeror has identified you as a reference to validate past performance.

Solicitation HT940625QE012 is for supplies; IDIQ Pre-filled Syringes and Bags at the Naval Medical Center Portsmouth located in Portsmouth, VA.

Please complete the following questionnaire to assist our evaluation of the offeror’s past performance and return via email no later than 5 pm Eastern Time on Monday, 1 September 2025 via email to lisa.c.wilk.civ@health.mil and carol.e.uebelacker.civ@health.mil. Please reference “Solicitation HT940625QE012” in the subject of the email.

RESPONDENT INFORMATION (to be completed by the Offeror):

Contracting Activity/Customer:

Point of Contact (POC):

Title of POC:

Telephone:

Email:

CONTRACT INFORMATION (to be completed by the Offeror):

Contract Number:

Task Order Number (if applicable):

Performance Period: (Base plus any options):

Description of Services (included position description(s)):

REQUIREMENT DESCRIPTION

Number of FTEs/description of required schedule:

Facility Type Services performed for (i.e., Hospital/Clinic):

All information from here down shall be completed by the Reference POC. The Reference POC shall also verify the information completed by the Offeror and make any necessary corrections before signing this form.

Please refer to the following assessment definitions to assess the Offeror’s performance in each of the areas listed in this questionnaire:

(E) Exceptional - The Offeror’s performance meets contractual requirements and exceeds many (requirements) to the Government’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the Offeror were highly effective.

(V) Very Good - The Offeror’s performance meets contractual requirements and exceeds some (requirements) to the Government’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the Offeror were effective.

(S) Satisfactory - The Offeror’s performance meets contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the Offeror appear or were resolved satisfactorily.

(M) Marginal - Performance does not meet some contractual requirements. The contractual performance reflects a serious problem for which the Offeror has not yet identified corrective actions or the Offeror’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 Offeror’s corrective actions appear or were ineffective.

(N) Not Applicable – Unable to assess the area.

Overall Fill Rate (CPARS “Quality of Service” Rating Area)

Provided qualified contract personnel IAW the terms and conditions of the contract.

Ensured that qualified contract personnel remained filled IAW the terms and conditions of the contract.

Recruited, placed and retained qualified contract personnel with minimal disruption for hard-to-fill (specialty) positions or at remote locations.

If other than “Satisfactory,” explain how the performance exceeds or does not meet contractual requirements:

On-Time Fill Percentage (CPARS “Schedule” Rating Area)

Provided qualified contract personnel on time IAW the terms and conditions of the contract.

Provided complete, current and accurate qualifying package for each contract personnel IAW the terms and conditions of the contract.

If other than “Satisfactory,” explain how the performance exceeds or does not meet contractual requirements:

Turnover Rate (CPARS “Management” Rating area)

Retained qualified contract personnel without frequent turnover and minimal operations disruption IAW the terms of the contract.

If other than “Satisfactory,” explain how the performance exceeds or does not meet contractual requirements:

Replenishment Rate (CPARS “Management” Rating area)

Planned for and provided replacement candidates during the life of the contract to, include pre-planned/unplanned absences and extended leave of absence to avoid disruption of services and/or work schedule IAW the terms of the contract.

If other than “Satisfactory,” explain how the performance exceeds or does not meet contractual requirements:

Would you award this firm another contract:

If you answered “No” provide an explanation:

Was the contract terminated for default or cause:

If you answered “Yes” provide an explanation:

Additional Comments:

Signature: _________________________________________ Date: __________________

Print Name: ________________________________________

Title: ______________________________________________

Telephone: _________________________________________

Thank you for your participation in providing a detailed and accurate history of past performance for this offeror.