Past_Performance_Questionnaire_Attachment_3.doc

ATTACHMENT 3

PAST PERFORMANCE QUESTIONNAIRE

The Regional Health Contracting Office – Central (RHCO-C) is conducting a small business set-aside acquisition. The offeror has identified you as a reference to validate past performance.

Please complete the following questionnaire to assist our evaluation of the contractor’s past performance, and return via email no later than Friday, 15 January 2016 to:

POC: Timothy T. Hoerz, RHCO-C, HCAA, MEDCOM, Fort Hood, TX.

EMAIL: timothy.t.hoerz.civ@mail.mil Name of Contractor being evaluated: ___________________________________________________

1. How long has your company had a contract with this contractor?

2. Type of service being provided?

3. Where is the location of this service?

4. What is the contract amount?

5. How many Full Time Equivalents (FTE) are on the contract?

6. Have there been late deliveries or other unsatisfactory performance resulting in additional contractual or administrative costs?

Yes No If “Yes,” explain:

The last three item numbers will discuss schedule performance, quality of service & customer relations. Please refer to the following:

Rating System:

(1) Exceptional - Performance meets contractual requirements and exceeds many to the contractor’s benefit. The contractual performance of the element being assessed was accomplished with few minor problems for which corrective actions taken were highly effective.

(2) Very Good - Performance meets contractual requirements and exceeds some to the Contractor’s benefit. The contractual performance of the element being assessed was accomplished with some minor problems for which corrective actions taken were effective.

(3) Satisfactory - Performance meets the contractual requirements. The contractual performance of the element being assessed contains some minor problems for which corrective actions taken appear or were satisfactory.

(4) Marginal - Performance does not meet some contractual requirements. The contractual performance of the element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The proposed actions appear only marginally effective or were not fully implemented.

(5) Unsatisfactory - Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element contains serious problem(s) for which corrective actions appear or were ineffective.

PAST PERFORMANCE QUESTIONNAIRE, Continued

7. Schedule Performance – Please rate overall compliance with reliability and timeliness of scheduled performance.

(1) Exceptional (5) Unsatisfactory (4) Marginal (3) Satisfactory (2) Very Good If other than “Satisfactory,” explain how the overall performance exceeds or does not meet contractual requirements:

8. Quality of Service – Please rate overall compliance with contract statement of work requirement.

(1) Exceptional (5) Unsatisfactory (4) Marginal (3) Satisfactory (2) Very Good If other than “Satisfactory,” explain how the overall performance exceeds or does not meet contractual requirements:

9. Business/Customer Relations – Please rate overall effective management; successfully managed services; reasonable/cooperative behavior; flexibility; business-like concern for customer’s interest.

(1) Exceptional (5) Unsatisfactory (4) Marginal (3) Satisfactory (2) Very Good If other than “Satisfactory,” explain how the overall performance exceeds or does not meet contractual requirements:

Signature:

Date: _____________________________ Print Name: ____________________________________ Company:

Title: __________________________________________ Telephone:

Thank you for your participation in providing a detailed and accurate history of past performance for this offeror.