DRAFT_Attachment_J.3.3_-_Past_Performance_Questionnaire_Instructions_and_Response.pdf

DRAFT

RFP-CMS-2016-8A-0008 Workers Compensation Review Contractor

Attachment J.3.3 – Past Performance Questionnaire Instructions and Response

Source Selection Information – See FAR 2.101 and 3.104

INSTRUCTIONS FOR PAST PERFORMANCE 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.

The questionnaire is arranged by general performance areas, i.e., quality of service, cost control, management performance, etc. Each area consists of a few basic questions relating to that aspect of 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

0 Performance was extraordinarily poor and required a very high degree of management intervention 1 Below average behavior with a significant number of problems in meeting requirements 2 Average behavior in which all requirements were met satisfactorily with few problems 3 Above average behavior with only very minor and insignificant problems 4 Performance frequently exceeded expectations

++/5 Performance was exceptional and consistently exceeded expectations

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 complete 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 e-mail your response to Stephen Stoyer at

Stephen.Stoyer@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 either during or after this survey has been completed.

mailto:Stephen.Stoyer@cms.hhs.gov

Attachment J.3.3 – Past Performance Questionnaire Instructions and Response

Source Selection Information – See FAR 2.101 and 3.104

PAST PERFORMANCE QUESTIONNAIRE

Solicitation No. RFP-CMS-2016-8A-0008

Contractor: _____________________ Referenced Agency: ______________________

Address: _____________________ Contact Person: ______________________

_____________________ Telephone No.: ______________________

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

Q2. What type of contract?

Q3. Competitive or non-competitive?

Q4. Total value of contract?

Q5. 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 0-

Unsatisfactory 1-Poor 2-Fair 3-Good 4-Excellent ++5 - Demonstrated Exceptional Performance

Q6. How was the contractor's quality of products/services? (compliance with contract requirements - accuracy of reports submitted - technical excellent/appropriateness of personnel)

Comments: Rating:

++5

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)

Comments: Rating:

++5

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)

Comments: Rating:

++5

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)

Comments: Rating:

++5

Q10. Was the contractor's performance generally satisfactory?

a. Yes

b. No

Attachment J.3.3 – Past Performance Questionnaire Instructions and Response

Source Selection Information – See FAR 2.101 and 3.104

Q11. Would you recommend this contractor others?

a. Yes

b. No

Q12. Any other comments regarding the contractor's performance?

Comments:

PRINT NAME: ____________________________________

SIGNATURE: ____________________________________

TITLE: ____________________________________

DATE: ____________________________________