J.6-Past_Performance_Questionnaire.doc

Attachment J.6-Past Performance Questionnaire

RFP-CMS-2015-8A-NSTP

INSTRUCTIONS FOR QUESTIONNAIRE RESPONSE

The information from this questionnaire will be utilized in accordance with the 1994 Federal Acquisition Streamlining Act, Section 1091 to evaluate the past performance of offerors, and will augment information available via the PPIRS system.

The questionnaire is arranged by general performance areas, i.e., quality of service, cost, control, management performance. We ask that you rate the contractor on a scale of 0 through ++/5 by circling the appropriate number with 0 being unsatisfactory, 2 fair and 5 exceptional. The following table describes the rating scale in more detail:

We request that you justify each of your ratings with a comment. Please be as specific in your comment as possible, especially of situations that warranted very high or very low ratings. Use extra pages as necessary.

Finally, please consider the remainder of the questionnaire by circling the appropriate answer. In addition, please sign your name and identify your position during your association with the referenced contract. Once completed, please scan and send a PDF file to: Jeannine Bohlen, Contract Specialist, at: Jeannine.Bohlen@cms.hhs.gov .

Category 0 or 1 responses will be referred to the contractor to permit rebuttal. Neither your name nor position within your organization will be divulged during or after this survey has been completed.

PAST PERFORMANCE QUESTIONNAIRE

Solicitation No: _____________________

Contractor: ________________________ Entity Providing Reference: ________________

Address: __________________ Contract Person: _________________

Telephone Number: __________________

Q1. What type of product(s)/services was provided under your contract?

Q2. What type of contract?

Q3. Total value of contract:

Q4. Period of performance?

Ratings: Summarize contractor’s performance and circle in the column on the right the number which corresponds to the performance rating for each rating category, see rating Guidelines for explanation of rating scale.

0-Unsatisfactory 1-Poor 2-Fair 3-Good 4-Excellent ++Demonstrated Exceptional Performance

Q5. How was the contractor’s quality of products/services?

(compliance with contract requirements-accuracy of reports submitted-technical excellent/appropriateness of personnel)

Q6. How well did the contractor control costs?

(written budget (over/under target costs)-contractor provided current, accurate and complete billings-relationships of negotiated costs to actual-cost efficiencies)

Q7. How well did the contractor comply with timeliness?

(did contractor meet interim milestones-reliable-responsive to technical direction-met all delivery schedules on time)

Q8. How well did the contractor work with project/contracting officers?

(prompt notification of problems-reasonable, cooperative, flexible-proactive-responsive to contract requirements-recommended solutions)

Q9. How would you describe the contractor’s commitment to customer satisfaction?

(how well did the contractor interface with the end user of the product/service)

Q10. How well do you assess the contractor’s key personnel?

(how long did key personnel stay on contract-did they effectively manage contract-were they responsive to technical direction)

b. No

b. Most

c. Half

d. Little

e. None

f. Not Applicable

b. No

b. Uncertain

c. No

b. Moderately cooperative

c. Slightly cooperative

d. Slightly uncooperative

e. Moderately uncooperative

f. Highly uncooperative

g. No opinion

b. Occasionally

c. Often

d. Always, or almost always

b. No

b. No

b. No

PRINT NAME: ________________________________

SIGNATURE: _________________________________

TITLE: _______________________________________

DATE: ________________________________________

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