ATTACHMENT 5 - Past Performance Questionnaire.docx

Attachment 5

W81K0025QA135

PAST PERFORMANCE QUESTIONNAIRE

The Medical Readiness Contracting Office – West (MRCO-W) is conducting a competitive acquisition for a non-personal services contract to obtain trauma registrar services to complete trauma registry charts that comprise the BAMC trauma registry backlog. The contractor will ensure accurate, timely, and complete abstraction, coding, and data entry of trauma patient information in compliance with all applicable accreditation, regulatory, and organizational requirements for Brooke Army Medical Center (BAMC), JBSA Ft Sam Houston, TX. at (BAMC), Level I Trauma Center, JBSA, Fort Sam Houston, Texas. 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 to cathy.l.harris2.civ@health.mil and james.m.davis1.civ@health.mil by 14 Jul 2025, 2:00PM CT

Name of Contractor being evaluated:

Note: Clearly identify and provide the name of the Prime Contractor and Subcontractor. Specify Prime Contractor/Subcontractor if known.

Contract/Order Number: __________________________________________________________________

1. Type of service being provided?

2. Where is the location of this service?

3. What is the total contract amount?

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

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

Yes |_| No |_| If “Yes,” explain:

The last two questions will discuss quality of service & customer relations. Please refer to the following:

Rating System:

(1) Excellent – Overall performance exceeds contractual requirements and gives extra benefits to the customer. Problems, if any, were promptly corrected without negative impact to the customer.

(2) Satisfactory – Performance meets contractual requirements. The contractual performance contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory

(3) Marginal - Performance does not meet some contractual requirements. The contractor’s proposed actions to correct any problems appear only marginally effective or were not fully implemented.

(4) Unsatisfactory – Performance does not meet most contractual requirements. The contractual performance contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

IMPORTANT NOTE: NARRATIVES MUST BE PROVIDED FOR ANY RATING OTHER THAN SATISFACTORY AND MUST SUPPORT THE RATING GIVEN.

PAST PERFORMANCE QUESTIONNAIRE, Continued

6. Quality of Service – Please rate overall compliance with the contract Performance Work Statement.

(1) Excellent |_| (2) Satisfactory |_| (3) Marginal |_| (4) Unsatisfactory |_|

If other than “Satisfactory,” a narrative must be provided to explain how the overall performance exceeds or does not meet contractual requirements:

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

(1) Excellent |_| (2) Satisfactory |_| (3) Marginal |_| (4) Unsatisfactory |_|

If other than “Satisfactory,” a narrative must be provided to 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.