S14 Attachment 4 - Past Performance Survey (86615625R00005).docx
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- Attached to
- Office of Healthcare Programs (OHP) requires contractor support to provide hospital assessment services.
- Solicitation number
- 86615625R00005
About this file
This is a Past Performance Survey template for solicitation number 86615625R00005, issued by the Department of Housing and Urban Development (HUD), Office of Healthcare Programs. The survey is designed to be completed by references identified by offerors to evaluate contractor or key personnel past performance on relevant projects. Offerors must provide project identification information including the contractor or key personnel name, contract or order number, project title, and total period of performance. References complete the survey by providing their name, title, agency or customer, phone number, and email address.
The survey evaluates five performance criteria, each rated on an adjectival scale: Quality of Service, Schedule, Cost Control, Business Relations, and Management of Key Personnel. Each criterion offers five rating options—Exceptional, Very Good, Satisfactory, Marginal, or Unsatisfactory—with detailed definitions provided for each level. Cost Control includes a "Not Applicable" option with an explanation requirement if selected. References must provide written comments substantiating any rating marked as Exceptional, Very Good, Marginal, or Unsatisfactory. The template was last updated on March 2, 2021, and serves as an attachment to the broader hospital assessment services solicitation with proposals due March 19, 2026.
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Attachment 4 - Past Performance Survey
PAST PERFORMANCE SURVEY
SOLICITATION NUMBER: 86615625R00005
This past performance survey is to be completed on the designated contractor or key personnel as designated below:
PAST PERFORMANCE PROJECT IDENTIFICATON (To be filled out by the Offeror):
| CONTRACTOR OR KEY PERSONNEL NAME: |
| Click here to enter text. |
| CONTRACT or ORDER NUMBER: |
| Click here to enter text. |
| PROJECT TITLE: |
| Click here to enter text. |
| TOTAL PERIOD OF PERFORMANCE, INCLUDING OPTIONS |
| Click here to enter text. |
PAST PERFORMANCE REFERENCE INFORMATION (To be filled out by the Reference):
| NAME: |
| Click here to enter text. |
| TITLE: |
| Click here to enter text. |
| AGENCY or CUSTOMER: |
| Click here to enter text. |
| PHONE: |
| Click here to enter text. |
| Click here to enter text. |
The Department of Housing and Urban Development (HUD) is procuring the services described in the box below. You have been selected by the contractor or key personnel identified above to provide past performance information to HUD to be used in evaluating the offeror’s proposal for this acquisition. Thank you for your input.
For each of the Five (5) criteria listed below, the rater must choose One (1) Adjectival Rating by checking the box, as applicable. At a minimum, for any rating that is checked Exceptional, Very Good, Marginal or Unsatisfactory, please submit additional comments to substantiate the rating. If Cost Control is N/A, please explain why.
1. QUALITY OF SERVICE
| RATING |
| Adjectival Rating |
| Definition |
Exceptional Performance meets contractual requirements and exceeds many to the Government’s benefit. The element being assessed was accomplished with few minor problems for which corrective actions taken by the Contractor/Key Personnel were highly effective
Very Good Performance meets contractual requirements and exceeds some to the Government’s benefit. The element being assessed was accomplished with some minor problems for which corrective actions taken by the Contractor/Key Personnel were effective
Satisfactory Performance meets contractual requirements. The element being assessed contains some minor problems for which corrective actions taken by the Contractor/Key Personnel appear or were satisfactory
Marginal Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the Contractor/Key Personnel has not yet identified corrective actions.
Unsatisfactory Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The element being assessed contains a serious problem(s) for which the Contractor’s/Key Personnel’s corrective actions appear or were ineffective.
ADDITIONAL COMMENTS:
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2. SCHEDULE
| RATING |
| Adjectival Rating |
| Definition |
Performance meets contractual requirements and exceeds many to the Government’s benefit. The element being assessed was accomplished with few minor problems for which corrective actions taken by the Contractor/Key Personnel were highly effective
Performance meets contractual requirements and exceeds some to the Government’s benefit. The element being assessed was accomplished with some minor problems for which corrective actions taken by the Contractor/Key Personnel were effective
Performance meets contractual requirements. The element being assessed contains some minor problems for which corrective actions taken by the Contractor/Key Personnel appear or were satisfactory
Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the Contractor/Key Personnel has not yet identified corrective actions.
Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The element being assessed contains a serious problem(s) for which the Contractor’s/Key Personnel’s corrective actions appear or were ineffective.
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3. COST CONTROL
| RATING |
| Adjectival Rating |
| Definition |
Performance meets contractual requirements and exceeds many to the Government’s benefit. The element being assessed was accomplished with few minor problems for which corrective actions taken by the Contractor/Key Personnel were highly effective
Performance meets contractual requirements and exceeds some to the Government’s benefit. The element being assessed was accomplished with some minor problems for which corrective actions taken by the Contractor/Key Personnel were effective
Performance meets contractual requirements. The element being assessed contains some minor problems for which corrective actions taken by the Contractor/Key Personnel appear or were satisfactory
Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the Contractor/Key Personnel has not yet identified corrective actions.
Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The element being assessed contains a serious problem(s) for which the Contractor’s/Key Personnel’s corrective actions appear or were ineffective.
Not Applicable
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4. BUSINESS RELATIONS
| RATING |
| Adjectival Rating |
| Definition |
Performance meets contractual requirements and exceeds many to the Government’s benefit. The element being assessed was accomplished with few minor problems for which corrective actions taken by the Contractor/Key Personnel were highly effective
Performance meets contractual requirements and exceeds some to the Government’s benefit. The element being assessed was accomplished with some minor problems for which corrective actions taken by the Contractor/Key Personnel were effective
Performance meets contractual requirements. The element being assessed contains some minor problems for which corrective actions taken by the Contractor/Key Personnel appear or were satisfactory
Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the Contractor/Key Personnel has not yet identified corrective actions.
Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The element being assessed contains a serious problem(s) for which the Contractor’s/Key Personnel’s corrective actions appear or were ineffective.
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5. MANAGEMENT OF KEY PERSONNEL
| RATING |
| Adjectival Rating |
| Definition |
Performance meets contractual requirements and exceeds many to the Government’s benefit. The element being assessed was accomplished with few minor problems for which corrective actions taken by the Contractor/Key Personnel were highly effective
Performance meets contractual requirements and exceeds some to the Government’s benefit. The element being assessed was accomplished with some minor problems for which corrective actions taken by the Contractor/Key Personnel were effective
Performance meets contractual requirements. The element being assessed contains some minor problems for which corrective actions taken by the Contractor/Key Personnel appear or were satisfactory
Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the Contractor/Key Personnel has not yet identified corrective actions.
Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The element being assessed contains a serious problem(s) for which the Contractor’s/Key Personnel’s corrective actions appear or were ineffective.
Click here to enter text.
MAR 2021
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