att 30 PPQ.doc

PAST PERFORMANCE QUESTIONNAIRE

I. Reference Identification A. Name of Reference/Activity

(Include point of contact/ Phone #/Fax #/Email )

II. CONTRACT IDENTIFICATION

A. Contractor [Insert Name of Offeror]

B. Contract Number C. Contract Type Competitive [ ] Yes [ ] No

Follow-On [ ] Yes [ ] No

D. Period of Performance E. Estimated Contract Total Including all option periods)

F. Description of Services Provided G. Geographic Distribution of Services Under This

Contract, (i.e., Local, Nationwide, Worldwide)

H. Number of Locations serviced by this Contract

III. EVALUATION

Below are listed specific questions relating to the following five categories fo contractor performance: quality, timeliness, cost, control, business relations, and customer satisfaction. Please rate the contractor for each question on a scale from 1 to 5, 5 being the best rating and 1 being the worst rating, or N/A for not applicable. There is a comment section provided below each question. Please document any responses receiving a rating of 2 or 1.

[ ] 5 - Considerably surpassed minimum requirements

[ ] 4 - Exceeded minimum requirements

[ ] 3 - Met minimum requirements

[ ] 2 - Less than minimum requirements

[ ] 1 - Efforts had a negative effect

A. QUALITY OF PRODUCT OR SERVICE

1. To what extent did the contractor comply with the specific contract requirements?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment:

2. How effective has the contractor been in providing the required supplies and/or services?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment:

3. To what extent did the contractor respond to technical directions, quality improvement recommendations, contract change orders, etc.?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment:

4. Did the contractor commit adequate resources in timely fashion to the contract?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment:

B. TIMELINESS OF PERFORMANCE

1. To what extent did the contractor adhere to contract delivery of performance schedules?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment:

2. To what extent did the contractor meet the response times in the contract?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment:

C. COST CONTROL

1. To what extent did the contractor provide current, accurate, and complete billings?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment:

2. To what extent did the contractor ensure only the supplies and/or services ordered were provided (unless required for intervention in life threatening emergencies)?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment:

3. To what extent did the contractor exhibit efforts to control costs while providing quality supplies and/or services?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment:

D. BUSINESS RELATIONS

1. To what extent was the contractor able to solve contract performance problems without extensive guidance from Government counterparts (COTR)?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment:

2. To what extent was the contractor effective in interfacing with Government staff?

[ ] 5 [ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] N/A

Comment:

E. CUSTOMER SATISFACTION

1. Has this contract been partially or completely terminated for default or convenience?

[ ] Yes for: [ ] Default [ ] Convenience

[ ] No

If yes, please explain (e.g., inability to meet cost, performance, or delivery schedules).

2. Are there any pending terminations?

[ ] Yes [ ] No

If yes, please explain and indicate the status.

3. How would you describe the level of health care services provided by the contractor?

[ ] Excellent [ ] Good [ ] Fair [ ] Unacceptable Comment:

4. Would you recommend this contractor for the award of additional contracts?

[ ] Yes [ ] No

Comment:

NARRATIVE SUMMARY

Use this section to explain additional information not included above.

Attachment 30