Tech Exh 3 - Past Performance Questionnaire.docx

PART 7, TECHNICAL EXHIBIT 3

Past Performance Questionnaire

Past Performance Questionnaire for Solicitation HT0011-19-R-0029, Military Health System Strategic (MHS) Strategic Communications Office Operational Support II: <<Prime Contractor fill in your company name here>>

The Defense Health Agency, Contracting Operations Division is conducting an evaluation of this company’s previous record of performance as part of a source selection process to award a contract for similar services. We respectfully request the reference fill out Part 2 and the reference forward this questionnaire: No later than the offer due date and time listed on the Page 1 of the subject solicitation, via email to pedro.m.godinez.civ@mail.mil and robert.e.leblanc6.civ@mail.mil. For questions related to this form, please contact: Pedro Godinez, Contract Specialist, at (703) 681-8768 or Robert LeBlanc, Contracting Officer, at (703) 681-1790.

PART I: THIS PART FOR COMPLETION BY PRIME OFFEROR ONLY. OFFERORS SHOULD COMPLETE ONE COPY OF THIS FORM FOR EACH REFERENCE PROVIDED.

Name of Individual/Firm being evaluated: __________________________________________________ Name of Firm/Agency for which the referenced work was performed:_____________________________ Name, address and phone number of the COR: _______________________________________________ Name, address and phone number of the Contracting Officer: ___________________________________ Was this work with a: Commercial __ Fed. Govt ___Local/state Govt __ entity.

Name, Title, Employer and Contact Information for Individual Providing Reference: _____________________________________________________________________________________ Period of Performance: ________________________________________________ Contract Award Date: _________________________________________________ Contract Completion Date: _____________________________________________ Check Contract Type: Fixed Price (FP)_ FP Incentive_ FP Economic Price Adjustment_ Award Fee_ Cost Plus Fixed Fee (CPFF) completion_CPFF Term_ CP Incentive Fee_ Cost Plus Award Fee_ Indefinite Delivery/Indefinite Quantity_ Basic Ordering Agreement_ Requirement_ Labor Hour_ Time and Material_ Sealed Bid_ Negotiated_ Competitive_ Non-competitive_ Contract Amount: ___________________ Prime Contractor: YES NO PWS paragraph(s) that the reference applies to: __________________________________________ The contract number and services provided: _________________________________________________________ Relevance of the referenced contract to the current requirement: ____________________

PART II: THIS PART FOR COMPLETION BY REFERENCE ONLY. References are asked to complete all items set forth in this Part II and return the completed form by No later than the offer due date and time listed on the Page 1 of the subject solicitation. The reference must remit this form via email; filled out in its entirety, directly to pedro.m.godinez.civ@mail.mil, the Contract Specialist and robert.e.leblanc6.civ@mail.mil, the Contracting Officer. The past performance questionnaire must NOT be sent by the Offeror to the Contract Specialist.

For each performance element identified below, references should evaluate performance of the firm or individual identified in Part 1 of this form. Where the reference lacks sufficient information to provide an evaluation for a particular performance element, this should be noted. Where any deficiency or unfavorable information is identified, the reference should identify any mitigating factors that may weigh in favor for the person/firm on whose behalf the reference is provided (i.e., problems due to causes outside the contractor’s control). An individual within your organization that is knowledgeable of the contractor’s day-to-day operations and overall performance should complete this questionnaire.

Name of Respondent: _______________________________________________ Position and Title: __________________________________________________ Telephone Number: _______________________FAX Number: _____________ Email Address:____________________ Address:________________________________________________________ Date Questionnaire was Completed: _____________ Detailed description of Work/Requirement: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Contract Amount: ___________________ Was a Subcontracting Plan Required?__________ Contract Award Date: ____________Contract Completion Date: ________________________ On what basis are you qualified to evaluate the performance of subject firm/individual? ________________________________________________________________________________________________________________________________________________________________________________________________________________________

The following chart depicts the ratings that are to be used to evaluate the contractor’s performance:

There were problems, some of a serious nature, for which corrective action was only marginally effective.

Performance did not meet contractual requirements.

There were serious problems, and the contractor’s corrective actions were ineffective.

When responding to the questions listed, circle the letter that most accurately describes the contractor’s performance or situation. For any neutral, marginal, or unsatisfactory rating, please provide explanatory narratives in the remarks block. These narratives need not be lengthy, just detailed. If a question is not applicable, circle N/A. If you circle a Yes/No answer that is marked with an asterisk (*), please provide a corresponding explanation in the remarks block. If more space is required, use the back of the questionnaire or attach additional pages. Handwritten responses to this questionnaire are acceptable. However, if responses are handwritten, please print legibly.

Your time and effort in providing this vitally important information are greatly appreciated.

PERFORMANCE ELEMENTS:

QUALITY OF SERVICE

1. Contractor’s ability to meet minimum quality standards specified for E VG S N M U N/A performance.

TIMELINESS OF PERFORMANCE

BUSINESS RELATIONS

MANAGEMENT OF KEY PERSONNEL

timely fashion.

COMPLIANCE WITH ENVIRONMENTAL, SAFETY, HEALTH, AND SECURITY REQUIREMENTS

1. Has the Contractor ever received an Notices of Violations YES NO for Compliance with environmental laws or regulations?

COST MANAGEMENT

1. Extent to which the Contractor provided reliable, supportable E VG S N M U N/A cost estimates or proposals.

2. Extent to which the Contractor met the proposed cost estimates? E VG S N M U N/A

CONTRACTUAL CONSIDERATIONS

1. If a subcontracting plan was required, extent to which E VG S N M U N/A Contractor met applicable goals for small business participation.

2. Has an election even been made not to exercise an option YES No or continue relations due to contractor’s poor performance?

for default or convenience?

Partially _________ Completely ___________

*REMARKS

PART III: FOR COMPLETION BY GOVERNMENT:

Additional Comments (Please continue on a separate page if necessary).