Past Performance Questionnaire.docx
DOCX document 58 KB Posted
- Attached to
- THREE (3) MEDICAL RECORDS TECHNICIAN Federal contract opportunity
- Solicitation number
- W81K00-21-R-3023
- Issued by
- Department of the Army Medical Command
About this file
This document is a past performance questionnaire for a solicitation seeking proposals for three full-time equivalent medical records technician positions at Bayne-Jones Army Community Hospital in Fort Polk, Louisiana. The Regional Health Contracting Office-Central is conducting a competitive award process under solicitation number W81K00-21-R-3023 to provide non-personal services including assisting with coding records for inpatient stays, inpatient professional service rounds, ambulatory procedure visits, and emergency services for the Patient Administration Division. Offerors must identify references that will be contacted to validate their past performance by completing this questionnaire, with responses due no later than September 7, 2021. The questionnaire evaluates offerors on schedule performance, quality of service delivered, and business/customer relations based on a rating system of exceptional, very good, satisfactory, marginal, and unsatisfactory.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Amendment 3 Response to Questions QA 13-14.pdf | ||
| Amendment 2 Response to Questions QA 9-12.pdf | ||
| Amendment 1 Response to Questions QA 1-8.pdf | ||
| W81K0021R3023 Solicitation.pdf | ||
| W81K0021R3023 Solicitation.pdf | ||
| W81K0021R3023 Solicitation.pdf |
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Text version
PAST PERFORMANCE QUESTIONNAIRE
The Regional Health Contracting Office-Central is conducting a Competitive Award. The offeror has identified you as a reference to validate past performance.
1. Solicitation Number W81K00-21-R-3023, is for (3) Full Time Equivalent (FTE) Medical Records Technicians, at Bayne-Jones Army Community Hospital, Fort Polk, LA 71459.
Please complete the following questionnaire to assist our evaluation of the contractor’s past performance, and return via email no later than 7 September 2021 to Veronica M. Brooks at veronica.m.brooks2.civ@mail.mil; Regional Health Contracting Office – Central, JBSA, Fort Sam Houston, TX 78234
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)
(6) Unsatisfactory - Performance does not meet most contractual requirements and recovery is not likely in a manner. The contractual performance of the element contains serious problem(s) for which corrective actions appear or were ineffective.
1. 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:
2. Quality of Service – Please rate overall compliance with contract statement of work requirement.
(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:
3. Business/Customer Relations – Please rate overall effective management; successfully managed services; reasonable/ cooperative behavior; flexibility; business-like concern for customer’s interest.
(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:
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.
File details come from the government source that posted it. Updated .