HT941026QE007-Past Performance Questionnaire.docx

PAST PERFORMANCE QUESTIONNAIRE

The Defense Health Agency, Contracting Activity is conducting a competitive procurement and (Offeror to insert their company name) has identified you as a reference to validate past performance.

1. Solicitation Number HT941026QE007 is for On-call, As-needed Interventional Cardiologist Services for Tripler Army Medical Center (TAMC), Hawaii.

Please complete the following questionnaire to assist the Government in evaluating my company’s past performance, and return to me via email no later than (Offeror to insert their requested due date) to (Offeror to insert their email address)

RESPONDENT INFORMATION:

Contracting Activity/Customer:

Point of Contact (POC):

Title of POC:

Telephone:

Email:

OFFEROR’S REFERENCE INFORMATION:

Contractor Name:

Point of Contact (POC):

Telephone Number:

Email:

CONTRACT INFORMATION:

Contract Number:

Task Order Number:

Type of Contract:

Performance Period: (Base plus any options):

Description of Services:

MARKET SEGMENT

MAGNITUDE

Annual Contract Value:

Total Contract Dollar Value:

COMPLEXITY

Number of FTEs:

Number of Credentialed FTEs:

Number of Privileged FTEs:

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

Contractor performed on this contract as:

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

(E) Exceptional - The Contractor’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 Contractor were highly effective.

(V) Very Good - The Contractor’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 Contractor were effective.

(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 assess the area.

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

Provided qualified Health Care Workers (HCW) IAW the terms and conditions of the contract.

Ensured that qualified HCW’s remained filled IAW the terms and conditions of the contract.

Recruited, placed, and retained qualified HCW’s 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)

Provide qualified HCW’s on time IAW the terms and conditions of the contract.

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

Provided complete, current and accurate credentialing/privileging packages within established time frames 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 HCWs 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.

As of 7 Feb 25