PPQ_Army Reserve Holistic Health and Fitness.docx

Attachment: TBD

W81K0027RA002

PAST PERFORMANCE QUESTIONNAIRE

The Medical Acquisition Support Office (MASO) is conducting a competitive acquisition for non-personal services for 25 Full Time Equivalents (FTEs), to perform Holistic Health and Fitness services for the Army Reserve components as follows:

- Registered Dietitians – 5 FTEs

- Cognitive Performance Specialist – 5 FTEs

- Strength and Conditioning Coach – 10 FTEs

- Athletic Trainer – 5 FTEs

The offeror has identified you as a reference to validate past performance.

Please complete the following questionnaire to assist our evaluation of the contractor’s past performance, and return to nathaniel.w.trulove.civ@army.mil and salameya.paulouskaya2.civ@health.mil

Name of Contractor being evaluated:

Note: Clearly identify and provide the name of the Prime Contractor and Subcontractor. Specify Prime Contractor/Subcontractor if known.

1. Contract/Order Number:

2. Description of the service being provided:

3. Location of this service:

4. Period of performance:

5. Dollar Amount per each year of performance:

6. Total contract amount:

7. Labor categories and Full Time Equivalents (FTE) per each labor categories, total amount of FTEs:

8. Have there been any unsatisfactory performance resulting in additional contractual or administrative costs?

Yes |_| No |_| If “Yes,” explain:

The last two questions will discuss quality of service & customer relations. Please refer to the following:

Rating System:

(1) Excellent – Overall performance exceeds contractual requirements and gives extra benefits to the customer. Problems, if any, were promptly corrected without negative impact to the customer.

(2) Satisfactory – Performance meets contractual requirements. The contractual performance contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory

(3) Marginal - Performance does not meet some contractual requirements. The contractor’s proposed actions to correct any problems appear only marginally effective or were not fully implemented.

(4) Unsatisfactory – Performance does not meet most contractual requirements. The contractual performance contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

IMPORTANT NOTE: NARRATIVES MUST BE PROVIDED FOR ANY RATING OTHER THAN SATISFACTORY AND MUST SUPPORT THE RATING GIVEN.

PAST PERFORMANCE QUESTIONNAIRE, Continued

6. Quality of Service – Please rate overall compliance with the contract Performance Work Statement.

(1) Excellent |_| (2) Satisfactory |_| (3) Marginal |_| (4) Unsatisfactory |_|

If other than “Satisfactory,” a narrative must be provided to explain how the overall performance exceeds or does not meet contractual requirements:

7. Business/Customer Relations – Please rate overall effective management; successfully managed services; reasonable/cooperative behavior; flexibility; business-like concern for customer’s interest.

(1) Excellent |_| (2) Satisfactory |_| (3) Marginal |_| (4) Unsatisfactory |_|

If other than “Satisfactory,” a narrative must be provided to explain how the overall performance exceeds or does not meet contractual requirements:

Signature: Date: _________________

Print Name: Company:

Title: Telephone:

E-mail: ______________________________

Thank you for your participation in providing a detailed and accurate history of past performance for this offeror.