Past Performance Survey Form - BLANK.pdf
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- Solicitation number
- 75H70726Q00033
About this file
This is a Past Performance Survey form issued by the Department of Health and Human Services Indian Health Service for use in evaluating contractor performance during federal contract source selection processes. The form is marked as Source Selection Sensitive and Not For Public Release.
The survey consists of two main sections. The first section, "Specific Performance," contains five open-ended questions requiring narrative responses about the contract type provided, end goals and products delivered, patient population served, planning and staffing requirements and whether contract exceptions were met, and contract timeline adherence. The second section, "Past Performance Ratings," requires evaluators to assign ratings across multiple performance categories using a five-point scale: Excellent, Good, Acceptable, Marginal, and Unacceptable. These categories assess Quality of Service (six criteria including compliance with requirements, report accuracy, personnel effectiveness, and technical excellence), Cost Control (four criteria addressing cost forecasting, billing accuracy, and cost efficiencies), Timeliness of Performance (six criteria including milestone achievement and delivery schedules), Business Relations (eight criteria covering management effectiveness, responsiveness, and staff turnover), and Customer Satisfaction (three criteria including overall contractor recommendation). The form includes space for identifying the solicitation number, contractor name, client information (commercial or federal), project details, contract value, performance period, and contact information for government or commercial project managers. An "Additional Comments" section allows evaluators to provide supporting documentation for assigned ratings.
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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:
File details come from the government source that posted it. Updated .