RFQ0113-14_ATTACHMENT_D.pdf

ATTACHMENT D

PAST PERFORMANCE QUESTIONNAIRE

Name of individual or entity requesting reference:

The person/entity identified above has offered to contract with the United States Equal Employment Opportunity Commission to provide mediation services and has listed you as a reference

Please complete the form and submit it to the following EEOC contact listed below via mail, fax or e-mail no later than

NAME:

ADDRESS:

PHONE NUMBER:

E-MAIL ADDRESS:

REFERENCE INFORMATION:

Insert below the name of the contracting office, date of contract, name of contract administrator, where the individual or entity seeking a reference has provided mediation service for you during the past 3 years.

Contracting Office:

Date of Contract(s):

Name of Administrator:

1. How many cases/disputes did the person/entity mediate for you during the past 12 months?

How many cases/disputes the past 3 years? What was their resolution rate? How many times was the person/entity the lead mediator in the dispute?

3 p.m. local time:

Fax:

E-mail Address:

Address:

Name of EEOC Contact:

FAX NUMBER:

2. Are there indicators that would provide information comparing the person/entity's resolution rate to the expected norm of results, i.e, more or less favorable than expected?

3. What types of disputes were mediated by the person/entity for you/your program (EEO,family, consumer, interpersonal, community)? What percentage were EEO disputes? What was the percentage of disputes mediated in each category?

4. Were settlement agreements adequately crafted by the person/entity ? Did the person/entity draft written agreements? If not, why not? What level of assistance was required by your program to the person/entity in crafting the agreements?

5. Did you receive any complaints that implicated the person/entity's appearance of neutrality or underlying fairness of the assigned mediation? If so what were the circumstances ? In your view were the complaints justified? What remedial action was required, if any?

6. Did the person/entity properly perform the mediation(s) and necessary paperwork within the time frames set forth by you or your program? Were there any instances where the person/entity could not complete the mediation and any necessary paperwork associated with the mediation(s) within specified time frames and if so, what were the underlying circumstances?

7. How reliable was the person/entity's availability to undertake disputes ? Were there instances where the person/entity was unable to mediate for you? If so what were the circumstances? Was the person/entity usually available to mediate disputes when you needed them?

8. How reliable was the person/entity to contact and return messages related to scheduling, conducting or the completion of a mediation?

9. Did the person/entity comport themselves professionally and did they execute the necessary procedures of your program?

10. What level of assistance was required by your program/contract administrator in overseeing the person/entity's assignments?

11. What is your assessment of the person/entity's understanding of equal employment opportunity law and EEOC procedures?

12. EEOC is a federal agency with limited resources. It is critical to the success of our mission to secure effective vendors. Is there any other information that you would like to provide concerning the person/entity? Would you award another contract with this person/entity again?

I attest that the information that I have provided to the United States Equal Employment Opportunity Commission concerning the person/entity seeking my reference is accurate and truthful.

Signed:

Print Name:

Date:

ATTACHMENT D

PAST PERFORMANCE QUESTIONNAIRE

The person/entity identified above has offered to contract with the United States Equal Employment Opportunity Commission to provide mediation services and has listed you as a reference

Please complete the form and submit it to the following EEOC contact listed below via mail, fax or e-mail no later than

REFERENCE INFORMATION:

Insert below the name of the contracting office, date of contract, name of contract administrator, where the individual or entity seeking a reference has provided mediation service for you during the past 3 years.

I attest that the information that I have provided to the United States Equal Employment Opportunity Commission concerning the person/entity seeking my reference is accurate and truthful.

8.0.1291.1.339988.308172