Appendix_A_Past_Performance_Questionnaire.pdf

Appendix A

PAST PERFORMANCE QUESTIONNAIRE

W81K00-17-R-0001

The Regional Health Contracting Office - Central 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 12:00pm CST on 6 Jan 2017 to Gregory.S.Knight.civ@mail.mil and Michelle.M.Bartkowski.civ@mail.mil.

Name of company being evaluated: _______________________________________________________________

How long have you done business with this company? ________________________________________________

Type of service being provided? __________________________________________________________________

What is the location of this service? _______________________________________________________________

What is the total contract amount? ________________________________________________________________

How many Full Time Equivalents (FTEs) are on the contract?

Was there unsatisfactory performance resulting in additional contractual or administrative costs?

Yes No

If yes, please explain:

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

Acceptable Unacceptable

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

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

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

3. 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 “Acceptable,” explain how the overall performance exceeds or does not meet contractual

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.