Past Performance Survey Form.docx
DOCX document 389 KB Posted
- Attached to
- AMENDMENT 003 - Four (4) Administrative Support Assistants - Santa Fe Indian Health Center
- Solicitation number
- 75H70726Q00035
About this file
This is a Past Performance Survey Form used by the Department of Health and Human Services Indian Health Service to evaluate contractor performance on relevant past contracts. The form collects information about specific projects including client details, contract numbers, total contract value, performance period, and project managers' contact information. Contractors are required to provide narrative responses describing the overall contract type, end goals and products, patient populations served, planning and staffing requirements, and contract timelines.
The survey employs a standardized rating system across five performance categories: Quality of Service, Cost Control, Timeliness of Performance, Business Relations, and Customer Satisfaction. Each category contains multiple evaluation criteria rated on a five-point scale (Excellent, Good, Acceptable, Marginal, or Unacceptable). Quality of Service metrics assess compliance with contract requirements, accuracy of reports, personnel effectiveness, technical excellence, adherence to specifications, and ability to serve nationwide including small and rural communities. Cost Control evaluates forecasting accuracy, billing completeness, cost relationship to actual expenses, and cost efficiencies. Timeliness of Performance measures milestone achievement, reliability, responsiveness to technical direction, on-time completion, delivery schedules, and liquidated damages. Business Relations and Customer Satisfaction sections evaluate contractor management, cooperation, problem notification, flexibility, small business subcontracting practices, staff turnover, and overall recommendation for future selection. The form includes space for additional comments supporting the assigned ratings.
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Text version
ATTACHMENT #3
| 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 Survey
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
Past Performance Survey
(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 .