W81K00-16-T-0129_Past_Performance_Questionnaire.pdf

PAST PERFORMANCE QUESTIONNAIRE

W81K00-16-T-0129

The Regional Health Contracting Office is conducting a competitive acquisition. The offeror has identified you as a reference to validate the offeror’s past performance. Please complete the following questionnaire to assist our evaluation of the contractor’s past performance, and return no later than 12:00 pm CDT on 31 May 2016 to michelle.m.bartkowski.civ@mail.mil or fax 210-221-3446.

Name of entity being evaluated: __________________________________

1. How long has your company had this contract/relationship with this contractor? _____________________

2. Type of service being provided? ________________

3. What is the location of this service? ________________

4. What is the total contract amount? _______________

5. Have there been unsatisfactory performance resulting in additional contractual or administrative costs?

Yes No

If yes, please explain:

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

(1) Exceptional (2)Very Good (3) Satisfactory (4) Marginal (5) Unsatisfactory

If other than “Satisfactory,” explain how the overall performance exceeds or does not meet contractual requirements:

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

If other than “Satisfactory,” explain how the overall performance exceeds or does not meet contractual

8. Business/Customer Relations – Please rate overall effective management; successfully managed services;

reasonable/cooperative behavior; flexibility; business-like concern for customer’s interest.

If other than “Satisfactory,” explain how the overall performance exceeds or does not meet contractual

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.

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.