J.9__PastPerformanceQuestionnaire.doc

Attachment J.9 Past Performance Questionnaire

PAST PERFORMANCE QUESTIONNAIRE

Sample Cover Letter

[COMPANY LETTERHEAD (Prime or subcontractor)]

Reference Name and Address

Date

SUBJECT: RFP #CMS-2007-0027 – Zone Program Integrity Contractor Dear _________________:

We are currently responding to the Centers for Medicare and Medicaid Services (CMS) Request for Proposal number CMS-2007-0027 (as a subcontractor to______ (If applicable)). The purpose of this contract is to provide fraud, waste and abuse detection, deterrence and prevention services for Medicare and Medicaid in accordance with the Zone Program Integrity Contractor program.

There is an increased emphasis on past performance in the federal source selection process. CMS is requesting that customers and clients of offerors provide the information as described within the attached questionnaire and return it to them for evaluation. We have identified you as one of our references and respectfully request that you complete and sign the attached questionnaire and then return it to CMS.

Questionnaires are due to CMS no later than __________________ (to be filled in by offeror - see L.I.3.1.D of the RFP), however, we would appreciate an earlier response if at all possible.

We sincerely appreciate your cooperation in this matter.

Sincerely, Department of Health & Human Services

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop C2-21-15

Baltimore, Maryland 21244-1850 Office of Acquisition and Grants Management

SUBJECT:

Solicitation RFP-CMS-2007-0027 – Zone Program Integrity Contractor, Past Performance Questionnaire To Whom It May Concern:

The Centers for Medicare & Medicaid Services (CMS) very much appreciates your time and thoughtfulness in completing the attached questionnaire. The information obtained from this questionnaire will be utilized to evaluate the past performance of Offerors/Contractors who wish to be awarded a contract with CMS. Please be advised that neither your name, nor position or organization, will be divulged before, during or after this survey has been completed.

The questionnaire is arranged by general performance areas, e.g., quality of service/performance, cost control, timeliness, management, etc. Each area consists of a few basic questions relating to these aspects of performance with regard to the Offeror/Contractor with which you worked. Please complete the questionnaire as indicated on the form.

Finally, please sign your name and identify your position during your association with the referenced Offeror/Contractor. Once completed, please submit the questionnaire in one of the following manners:

Email PDF (Preferred):

Gina.Romano@cms.hhs.gov E-mail is the preferred method.

Fax Original:

(410) 786-9643, ATTN: Gina Romano, (410) 786-8645 (Please advise by phone or e-mail if questionnaire will be faxed)

Mail Original:

Centers for Medicare and Medicaid Services

Office of Acquisition and Grants Management

Division of Medicare Support Contracts

ATTN: Gina Romano

(410) 786-8645 Contract Specialist

7500 Security Blvd., C22115

Baltimore, MD 21244-1850

Thank you for taking the time to complete the questionnaire.

Sincerely, Theresa Schultz

Contracting Officer

PAST PERFORMANCE QUESTIONNAIRE

CMS Solicitation No. RFP-CMS-2007-0027 – Zone Program Integrity Contractor Company Being Evaluated (Offeror) Offeror/Contractor:

Address:

Please complete the following questionnaire about the Offeror/Contractor and indicate your responses in the blocks or columns, as appropriate. Numerical ratings are as indicated in the Rating Scale below for Q6-Q11. Other Ratings are as indicated in each block. Note: Use of the term “Agency” can be interpreted as also Government/non-Government agencies or customers.

Rating Scale:

Although not required, we request that you justify each of your ratings with a comment. Please be as specific in your comment as possible, especially in situations that warrant very high or very low ratings. Use extra pages as necessary or expand the form electronically as needed.

Q1. What type of Product(s)/service(s) was/are provided by the Offeror?

Q2. What type of contract(s) (Firm Fixed Price, Cost Reimbursement, Time and Material, etc.), quantity, and subtotal dollar value of each type of contract(s) do/did you have with the Offeror?

Q3. Was the contract/subcontract(s) solicited competitively or noncompetitively?

Q4. Total value of the contract/subcontract(s) with the Offeror?

Q5. Period of Performance of the contract/subcontract(s)?

b. Most

c. Half

d. Little

e. None

f. Not applicable

b. No

b. Moderately Cooperative and Responsive

c. Slightly Cooperative and Responsive

d. Slightly Uncooperative and Unresponsive

e. Moderately Uncooperative and Unresponsive

f. Highly Uncooperative and Unresponsive

g. No opinion

b. Uncertain

c. No

b. Occasionally

c. Often

d. Always or almost always

b. No

b. No

b. No

Agency/Company COMPLETING Questionnaire

Agency/Company Name:

Address:

Signature of Individual Completing the Questionnaire:

Date

Name:

Telephone No.:

Title:

Email Address:

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