A.07.05_Past_Performance_Questionnaire_W81K00-16-T-0177.pdf

PAST PERFORMANCE QUESTIONNAIRE

W81K00-16-T-0177

San Antonio Military Medical Center, Fort Sam Houston, Texas

The Regional Health Contracting Office – Central (P) is conducting an acquisition for Medical Coding

Compliance Audit Services. 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 to: Robyn Villafranco at robyn.a.villafranco.civ@mail.mil NLT 18 July 2016 by 12:00 pm CST.

1. Name of vendor being evaluated: ___________________________________________________________

2. How long has your company had a contract with this vendor? _____________________________________

3. What type of services are provided? _________________________________________________________

4. What is the location of this service? _________________________________________________________

5. What is the contract number? ______________________________________________________________

6. What is the total contract value? ____________________________________________________________

7. Have any reports/schedules submittals been provided as required by the contract? _____________________

If not, provide a brief explanation: _____________________________________________________________

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

Yes _______ No _______

If yes, please explain:

mailto:robyn.a.villafranco.civ@mail.mil

The following questions should be answered using the following definitions:

ADJECTIVE DEFINITION AND CRITERIA

Acceptable

Based on the offeror’s performance record, there is a reasonable expectation that the offeror will successfully perform the required effort, or the offeror’s performance record is unknown.

Unacceptable

Based on the offeror’s performance record, there is no reasonable expectation that the offeror will be able to successfully perform the required effort.

9. Quality of Service: Compliance with contract statement of work requirement.

Acceptable ___ Unacceptable ___

Additional Information:

10. Business/Customer Relations: Successfully managed services; reasonable/cooperative behavior; flexible;

business-like concern for customer’s interest.

Acceptable ___ Unacceptable ___

Additional Information:

Signature: _______________________ Date: _____________________________

Print Name: ______________________ Company: _________________________

Title: ___________________________ Telephone: _________________________