Attachment 2 - Past Performance Questionnaire- Amendment 4.docx

PAST PERFORMANCE QUESTIONNAIRE

The Defense Health Agency Contracting Activity, Healthcare Contracting Division – West is conducting a solicitation among 8(a) small businesses set-aside. The offeror has identified you as a reference to validate past performance.

Solicitation Number, HT941026R2001 is for nonpersonal services of Integrated Referral Management and Appointing Center (IRMAC) services via centralized Patient Appointing Services (PAS), Referral Management Services (RMS), and Clear and Legible Report accountability Services (CLR) for Defense Health Network Indo-Pacific Military Treatment Facilities (MTF) in Hawaii and the Pacific Northwest (Pacific).

Please complete the following questionnaire to assist our evaluation of the Contractor’s past performance, and return via email no later than [Enter date] to [Enter point of contact information].

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:

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.

CPARS “Quality of Service” Rating Area

Provided quality services that met contract requirements, specifications and performance standards IAW the terms and conditions of the contract.

Provided quality personnel that met or exceeded the required qualifications

Maintained an effective on-going Quality Control Plan to monitor, analyze and improve quality contract performance.

Maintained an open line of communication so that the Contracting Officer’s Representative (COR) was informed of technical and cost issues

Cooperated with the Government in providing flexible, proactive and effective solutions to critical contract issues.

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

(CPARS “Schedule” Rating Area)

Met contract deliverables within established time frames IAW the terms and conditions of the contract.

Demonstrated an ability to quickly recruit contract service providers on time to meet the contract requirements.

Responded effectively to contract performance issues.

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

(CPARS “Management” Rating area)

Retained qualified workers 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:

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