Exhibit 14 - Past Performance.pdf

Exhibit 14

SOURCE SELECTION SENSITIVE (when completed)

PAST PERFORMANCE EVALUATION QUESTIONNAIRE

Program Support Center Department of Health and Human Services

I. CONTRACT INFORMATION

1a. Contractor:

1b. Contract Number

1c. Type of Contract: (check all that apply)

i. ( ) Negotiated ( ) Sealed Bid ii. ( ) Competitive ( ) Non-Competitive

iii. ( ) Firm Fixed-Price ( ) Fixed-Price Incentive () Fixed-Price Award Fee (Cost-Plus-Award-Fee)

( ) Cost-Plus-Incentive-Fee ( ) Cost-Plus-Fixed-Fee Other:

1d. Please complete the following:

Period of Performance: ___________ TO ____________

Initial Contract Value: $_____________

Current (or completed) Contract Value: $_______________________

1e. Brief description of requirement:

1f. Complexity of effort (check one): ( ) Difficult ( ) Routine

Exhibit 14

II. EVALUATOR INFORMATION: Please provide the following information (to assist us in tracking responses received and resolving any questions in the evaluation process if necessary):

Name of Evaluator: ______________________________________

Telephone Number: ______________________________________

Facsimile Number: ______________________________________

Organization/Office: ______________________________________

Mailing Address:___ ___________________________________________

Position Title/Grade:_____________ _________________________

Period of involvement in contract:____________________________

Questionnaire Completion Date:

III. RATING CATEGORIES: The following definitions for adjectival rating categories are provided for your convenience. Please rate each aspect of past performance by checking one of these categories in the spaces provided.

EXCEPTIONAL: The Contractor has demonstrated an excellent level of performance which (++ Plus-Plus) exceeds the performance level described as

“Excellent”. It is expected that this rating will be used in those rare instances when Contractor performance clearly demonstrates a level of quality/innovation/performance well beyond the contract requirements warranting the assignment of the highest possible rating.

EXCELLENT: Contractor demonstrates initiative to enhance/exceed contractual requirements/objectives and overall contractor/government relationship is exceptional.

GOOD: There are no quality of service problems and/or nonconformances do not impact achievement of contract requirements.

ACCEPTABLE: Nonconformances are minor and have little impact in achievement of contract requirements, requires minor intervention by Government personnel to resolve issues.

MARGINAL: Nonconformances are impacting achievement of contract requirements, requires substantial intervention by Government personnel to resolve issues.

UNACCEPTABLE: Nonconformances are compromising the achievement of contract requirements, despite substantive intervention by Government personnel.

Please check the appropriate rating category. Comment lines are provided for additional information if the MARGINAL or UNACCEPTABLE rating category apply (however the comment lines may be used to provide any additional information deemed noteworthy). If a question is not applicable, so indicate.

IV. QUALITY OF SERVICE: This area of the questionnaire deals with compliance of contract requirements, to include appropriateness of personnel and technical excellence.

4a. Overall compliance with contract terms and conditions.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

4b. Effectiveness and reliability of contractor's Key Personnel.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

4c. Adequacy of staffing to meet contract requirements.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

4d. Consistency and reliability of contractor's technical performance.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

4e. Ability to effectively implement "start-up" contract performance.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

V. TIMELINESS OF PERFORMANCE: This area of the questionnaire deals with the contractor's ability to meet milestones and delivery schedules, to include responsiveness to technical direction, completion of efforts on time including wrap-up and contract administration.

5a. Overall performance in planning, scheduling, and monitoring.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

5b. Completion of major milestones on schedule.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

5c. Responsiveness to contract changes from a contract administration perspective.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

5d. Responsivenss/capabilty to respond to surge/short term requirements.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

VI. PRICE/COST CONTROL: This area of the questionnaire deals with the contractor's ability to control price/cost escalation during performance to include appropriate budgetary estimates, current/accurate/complete billings/invoices, relationship of negotiated costs to actual, claim submissions, cost efficiencies, and change order issues.

6a. Quality, completeness, and accuracy of price/cost proposals.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

6b. Accuracy and timeliness of cost reports.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

6c. Ability of the Contractor to operate at or below budget.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

VII. CUSTOMER SATISFACTION: This area of the questionnaire deals with the contractor's commitment to satisfaction and cooperative/reasonable behavior with customers to include effective management, responsiveness to contract requirements, businesslike behavior, prompt notification of problems, flexible and proactive qualities, effective contractor-recommended solutions, and effective subcontracting and teaming arrangements.

7a. Organizational support structure provides adequate span of control and supervision.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

7b. Maintains a single effective point of contact to manage and resolve problems.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

7c. Ability to solve contract performance problems without extensive guidance from Government personnel.

Rating Category: ( ) Exceptional (++) ( ) Excellent ( ) Good ( ) Acceptable ( ) Marginal ( ) Unacceptable

VIII. GENERAL INFORMATION: Please provide answers to the following questions.

8a. Has the contractor ever been given a cure notice, show cause notice, suspension of progress payments, or letters of direction? ( ) Yes ( ) No

If yes, please explain:____________________________________________________________________________________________________

8b. Has this contract been partially or completely terminated? ( ) Yes ( ) No ( ) Default ( ) Convenience

If yes, please explain:____________________________________________________________________________________________________

8c. Are there any pending partial or complete terminations? ( ) Yes ( ) No ( ) Default ( ) Convenience

If yes, please explain and indicate status:_____________________________________________________________________________________

8d. If an award/incentive fee contract, what percent of the available fee did the contractor usually receive?

8e. Changes in contract dollar value throughout the life of the contract are/were attributable, for the most part, to ( ) Government-issued change orders ( ) claims submitted by the contractor ( ) other Government actions ( ) other contractor actions.

Please explain:_________________________________________________________________________________________________________

8f. Based on this contractor's overall performance, would you award this contractor another Government contract? ( ) Yes ( ) No

If no, please explain:____________________________________________________________________________________________________

Thank you for completing this past performance evaluation. THIS INFORMATION WILL BE KEPT CONFIDENTIAL.

Please fax this questionnaire to the fax number indicated below:

DHHS/PSC/SAS/DAM

Attention: Brendan Miller Fax: (301) 443-3849 Phone: (301) 443-2475

NOTE: This information will be held confidential to the extent allowed by the Freedom of Information Act, 5 U.S.C. 552(b) and the Department’s implementing public information regulations, 45 CFR part 5. It is the position of the Program Support Center (PSC) to protect, pursuant to Exemption 5 of the FOIA, information contained in these forms which would reveal the identities of the individual reviewers. Disclosure would inhibit full open and candid communications and evaluations which are necessary for informed contract decisions.

I. CONTRACT INFORMATION