PAST_PERFORMANCE_QUESTIONNAIRE.docx

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Orthopedic Clinics
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RFQ-10-19-012-KN
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D. 2 - Past Performance Questionnaire. To be filled out by references to the 3 current or past contracts/jobs submitted in response to past performance evaluation factor.

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Attachment_D.1_-_Price_Schedule_Worksheet.xlsx XLSX spreadsheet
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PAST PERFORMANCE QUESTIONNAIRE

1. CONTRACT INFORMATION: Complete the following information on the contractor that provided or is currently providing services for your company.

a.Period of Performance: _______________________
b.Total Contract Dollar Value: ______________________
c.Brief Description of Contracted Item(s) or Service(s): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. The following information will help us track the responses received, as well as resolve whatever differences may arise between your perception of the contractor’s performance and the contractor’s perception of their performance.

a.Reference Name:
b.Title:
c.Telephone Number:______
d.Date of questionnaire completion:

3. Please respond to the following questions regarding the contractor’s past performance.

a. Please rate the contractor’s personnel and their ability to perform the requirements of the contract.

|_| Exceptional
|_| Very Good
|_| Satisfactory
|_| Marginal
|_| Unsatisfactory
|_| Unknown

b. Please rate the contractor’s ability to provide quality services.

|_| Exceptional
|_| Very Good
|_| Satisfactory
|_| Marginal
|_| Unsatisfactory
|_| Unknown

c. Please rate the contractor’s ability to identify problems as they occurred.

|_| Exceptional
|_| Very Good
|_| Satisfactory
|_| Marginal
|_| Unsatisfactory
|_| Unknown

d. Please rate the contractor’s overall compliance with the contract terms and conditions.

|_| Exceptional
|_| Very Good
|_| Satisfactory
|_| Marginal
|_| Unsatisfactory
|_| Unknown

e. Please rate the contractor’s responsiveness to contract changes.

|_| Exceptional
|_| Very Good
|_| Satisfactory
|_| Marginal
|_| Unsatisfactory
|_| Unknown

f. Based on your judgment of the contractor’s performance, would you award the contractor another contract?

|_| Yes (please explain) |_| No (please explain)

g. Please rate your overall customer satisfaction with the contractor's performance.

|_| Exceptional
|_| Very Good
|_| Satisfactory
|_| Marginal
|_| Unsatisfactory
|_| Unknown

h. Did the contractor have adequate resources to complete the job?

|_| Exceptional
|_| Very Good
|_| Satisfactory
|_| Marginal
|_| Unsatisfactory
|_| Unknown

Additional Comments:

4. The evaluator will validate the past performance questionnaire by contacting the listed reference.

a.Evaluator’s Name:
b.Validated On:

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