Past Performance Survey Form - BLANK.pdf

ATTACHMENT

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Indian Health Service

Past Performance Survey Solicitation No.: Title:

Contractor Name:

CLIENT INFORMATION

Commercial Client Federal Client

Client Name:

Client Address:

City State Zip Code

Project Name:

Contract Number(s): Total Contract Value:

Performance Period: Teaming Partner(s):

Government or Commercial Project Manager Contact

Alternate Government or Commercial Project Manager Contact

Name: Name:

Title: Title:

Phone number: Phone number:

Fax number: Fax number:

E-mail address:__ E-mail address:

SPECIFIC PERFORMANCE

Instructions: This part consists of open-ended questions to determine the scope, complexity, and relevance of the contract to the current requirements. Please answer the questions concisely and to the best of your knowledge.

1. Describe the overall contract type the contractor provided.

2. Describe the end goal/end product and result.

3. Describe the general background type of the patients served in performing this task.

4. Describe the level of planning and staffing contractor was required to perform and if they met the contracts exceptions.

5. Describe the average timeline involved in completing this contract and if contractor met that timeline within reason.

SOURCE SELECTION SENSITIVE

NOT FOR PUBLIC RELEASE

PAST PERFORMANCE RATINGS

Please answer each of the following questions with a rating that is based on objective measurable performance indicators to the maximum extent possible. Comments to support ratings may be noted on last page. The Government will assess an overall past performance rating for each reference contacted. The overall ratings of each reference will then be combined to arrive at a final past performance rating that will be assigned points based upon the following rating scheme:

RATINGS ARE DEFINED AS FOLLOWS:

Definition Description

Excellent The Contractor demonstrates an excellent performance level in all categories. There have been no performance problems and the Contractor has demonstrated initiative to enhance/exceed contractual requirements and objectives.

The Contractor also has maintained an excellent Contractor/Government relationship throughout contract performance

Good There are no quality of service problems; no cost/price issues; and no delays. Responses to inquiries and technical/service administrative issues are consistently effective and responsive. Non-conformance does not impact achievement of contract requirements.

Acceptable Non-conformances are minor and have little impact in achievement of contract requirements, requires minor intervention by Government personnel to resolve issues.

Marginal Non-conformances are impacting achievement of contract requirements, requires substantial intervention by Government personnel to resolve issues.

Unacceptable Non-conformances are compromising the achievement of contract requirements, despite substantive intervention by Government personnel.

PART 1: GENERAL PERFORMANCE

INSTRUCTIONS: PLEASE CHECK THE APPROPRIATE RATING

Quality of Service Excellent Good Acceptable Marginal Unacceptable N/A

1. Compliance with contract requirements

2. Accuracy of Reports

3. Effectiveness of Personnel

4. Technical Excellence

5. Record of conforming to specifications and standards of good workmanship

6. Ability to provide services nationwide, including small and rural communities

Cost Control Excellent Good Acceptable Marginal Unacceptable N/A

1. Record of forecasting and controlling target costs

2. Current, accurate, and complete billings

3. Relationship of negotiated costs to actual

4. Cost efficiencies

Timeliness of Performance Excellent Good Acceptable Marginal Unacceptable N/A

1. Met interim milestones

2. Reliability

3. Responsive to technical direction

4. Completed on time including wrap up

5. Met delivery schedules

6. Amount of Liquidated Damages

(Excellent=Low or None, Unacceptable= High)

Business Relations Excellent Good Acceptable Marginal Unacceptable N/A

1. Effective Management, including subcontracts

2. Reasonable/cooperative behavior

3. Responsive to contract requirements

4. Notification of problems

5. Flexibility

6. Pro-active vs. Reactive

7. Effective small/small disadvantage business subcontracting program

8. History of staff turnover

Customer Satisfaction Excellent Good Acceptable Marginal Unacceptable N/A

1. Commitment to customer satisfaction

2. Would you recommend selection of this firm again?

3. Overall Rating of Contractor

ADDITIONAL COMMENTS: