Attachment 6- Past Performance Questionnaire.docx

PAST PERFORMANCE QUESTIONNAIRE

The Medical Readiness Contracting Office – West (MRCO-W) is conducting a competitive acquisition for Translation and Interpretation Services at Brooke Army Medical Center, JBSA Ft. Sam Houston, TX. 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 via email to dulce.i.bares.civ@health.mil and salameya.paulouskaya2.civ@health.mil.

RESPONDENT INFORMATION:

Contracting Activity/Customer:

Point of Contact (POC):

Title of POC:

Telephone:

Email:

OFFEROR’S REFERENCE INFORMATION:

Contractor Name:

Point of Contact (POC):

Telephone Number:

Email:

CONTRACT INFORMATION:

Contract Number:

Task Order Number:

Type of Contract:

Performance Period: (Base plus any options):

Description of Services:

MARKET SEGMENT

MAGNITUDE

Annual Contract Value:

Total Contract Dollar Value:

COMPLEXITY

Facility Type (i.e., Hospital/Clinic):

Contractor performed on this contract as:

Please refer to the following assessment definitions to assess the Contractor’s performance in each of the areas listed in this questionnaire:

(E) Exceptional - The Contractor’s performance meets contractual requirements and exceeds many (requirements) to the Government’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the Contractor were highly effective.

(V) Very Good - The Contractor’s performance meets contractual requirements and exceeds some (requirements) to the Government’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the Contractor were effective.

(S) Satisfactory - The Contractor’s performance meets contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the Contractor appear or were resolved satisfactorily.

(M) Marginal - Performance does not meet some contractual requirements. The contractual performance reflects a serious problem for which the Contractor has not yet identified corrective actions or the Contractor’s proposed actions appear only marginally effective or were not fully implemented.

(U) Unsatisfactory - Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance contains serious problem(s) for which the Contractor’s corrective actions appear or were ineffective.

(N) Not Applicable – Unable to assess the area.

certifications (CPARS “Quality of Service” Rating Area)

Personnel Certification

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

Response time (CPARS “Schedule” Rating Area)

Service response time

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

(CPARS “Management” Rating area)

How did the vendor handle emergency requests

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

Would you award this firm another contract:

If you answered “No” provide an explanation:

Was the contract terminated for default or cause:

If you answered “Yes” provide an explanation:

Additional Comments:

Signature: _________________________________________ Date: __________________

Print Name: _________________________________________

Title: _______________________________________________

Telephone: __________________________________________

Thank you for your participation in providing a detailed and accurate history of past performance for this offeror.