Attachment 4 - Past Performance Survey 01-11-2012.doc

Attachment #4 - National Institutes of Health, Clinical Center IFB NIHCL2011096R – Linen Replacement

Past Performance Questionnaire -2

Past Performance Questionnaire (To be completed by Contractor’s client/customer)

INSTRUCTIONS:

The questions contained below are to be used to evaluate the performance record of a contractor submitting a proposal in response to the IFB issued by the National Institutes of Health for Information Technology Support.

Please complete this performance questionnaire and return to:

Mr. Brian Lind, Contract Specialist

National Institutes of Health, Clinical Center, Office of Purchasing and Contracts, 6707 Democracy Blvd., Suite 106, Room F Bethesda, Maryland 20892-5480

By February 13, 2012, fax is acceptable at (301)-480-0669. Your responses to this questionnaire will be considered confidential, except as explained below. Responses returned by contractors will not be used in the performance evaluation. For the purposes of this survey, “Contractor” refers to the specific contractor that requested you to provide this information to the Government.

For each of the following areas, rate the performance of the Contractor as (5) Outstanding; (4) Excellent; (3) Good; (2) Fair; (1) Poor; (0) Unsatisfactory; or (N/A) Not Applicable. Indicate your rating by circling the appropriate number.

Include a narrative explanation whenever you feel that it is appropriate, but as a minimum when a rating of “Unsatisfactory” is given. Please note that if an “Unsatisfactory” rating is given, the contractor will be made aware of it and will be asked to comment.

This survey pertains to: NIHCL2011096 – Hospital Linens Name of Company Completing Survey:

Department/Component:

Contract Number:

Date of Survey:

Name of Person Completing Survey:

Signature of Person Completing Survey:

Your Role in this Contract (circle one):

Contracting Officer Contract Specialist Project Officer Other Contract Value (including options if applicable): $ Performance Period: (including option periods) Type of Contract:

Please supply the subcontractor(s), program manager and phone number; add lines if needed.

Subcontractor

Program Manager

Phone

General description of products/services required under the contract:

RATINGS

Please answer each of the following questions with a rating that is based on objective measurable performance indicators to the maximum extent possible. Commentary to support rating shall be noted on page 4.

Assign each area a rating of 0 (Unsatisfactory), 1 (Poor), 2 (Fair), 3 (Good), 4 (Excellent), or 5 (Outstanding). Use the attached Rating Guidelines as guidance in making these evaluations. Circle the appropriate rating. If you do not have enough personal knowledge or feedback from internal customers who directly received products and services from the contractor to make a determination on any of the performance criteria below, please circle "N/A" (not applicable/no opinion).

QUALITY OF SERVICE (WAS REQUIREMENTS RECEIVED PROMPTLY AND COMPLETE)

1.

Compliance with contract requirements

N/A

2.

Accuracy of reports

N/A

3.

Effectiveness of personnel

N/A

4.

Technical Excellence

N/A

QUALITY OF LINENS

1.

Compliance with contract requirements

N/A

2.

Accuracy of reports

N/A

3.

Effectiveness of personnel

N/A

4.

Technical Excellence

N/A

BUSINESS RELATIONS

1.

Effective management

N/A

2.

Reasonable/cooperative behavior

N/A

3.

Responsive to requirements

N/A

4.

Notification of problems

N/A

5.

Flexibility

N/A

6.

Pro-active vs. reactive

N/A

CUSTOMER SATISFACTION

1.

The contractor is committed to customer satisfaction.

Yes No (circle one) 2.

Would you recommend selection of this firm again?

Yes No (circle one) ADDITIONAL COMMENTS (attach page for comments)

Rating Guidelines

service/ administrative issues is not effective

service/ administrative issues is marginally effective

inquiries, technical/ service/ administrative issues is somewhat effective

errors have been identified

inquiries, technical/ service/ administrative issues is usually effective

inquiries, technical/ service/ administrative issues is effective

Signature:______________________Organization:_________________ Title:__________________________Date:_________________________

01-11-2012