Attachment J-4 Past Performance Questionnaire.docx

Past Performance Questionnaire Centralized Medical Credentialing & Privileging Support Services The organization named below is asking you to be a past performance reference by completing this questionnaire. The Government refers to this organization as the Offeror. You are the client.

This questionnaire is part of the offeror’s response in a Government source selection. By requesting you to complete this questionnaire, the offeror intends to use you as a reference for Government source selection evaluation purposes. The Government considers the information you provide here to be Source Selection Sensitive and confidential. The Government intends to use this data only for this source selection.

The Government asks that your answers to questions be honest and forthright, and that they be based only on your direct personal knowledge of the offeror. The Government will not share your responses outside of this source selection. To ensure fairness and impartiality, you are to e-mail your completed and signed questionnaire directly to the Government to cole.p.cook.civ@mail.mil and hillari.k.hawkins.civ@mail.mil. Be aware that the offeror is not to participate in your questionnaire responses in any way whatsoever.

This questionnaire has three parts. The offeror has to complete Part I. In Part I, the offeror tells you the particular contract or project he/she wants to use as his/her reference. Part II is your responsibility. In Part II, the questionnaire asks you to provide performance information about the referenced contract or project. Part III contains definitions to help you in your assessments. You will have to refer to these definitions to accurately complete the questionnaire.

If for any reason you are unable to complete this questionnaire, please complete item 10 in Part II and forward this questionnaire to the Government using the above specified email addresses.

Part I: Reference Background Information Part I of this questionnaire is to be completed by the offeror.

Client and Reference Project/Contract Information (Completed by Offeror)

Part II: Past Performance Questions You are requested to complete Part II of this questionnaire, which involves filling out the CLIENT ASSESSMENT OF PAST PERFORMANCE table. There are four factors to address: Technical, Management, Quality of Service and Improvement, and Responsiveness to Customer. You are to assess each factor and mark an X in the appropriate column in the table.

Please use the ratings scheme defined in Part III of this questionnaire. In addition, please study the performance category definitions, rating definitions, and the rating scheme found in Part III of this questionnaire before assessing client performance.

Client Assessment of Past Performance

Technical

Management

Quality of Service and Improvement

Responsiveness to Customer

If your rating for any factor is excellent or unsatisfactory, please provide supporting data as requested below.

Remarks on Outstanding performance: provide data supporting this observation; you may continue on a separate sheet if needed.

Remarks on Unacceptable performance: provide data supporting this observation; you may continue on a separate sheet if needed.

Please identify any corporate affiliation you have with the offeror:

Other comments that you wish to make: you may continue on a separate sheet if needed.

Would you do business with ______________________________________again?

(Insert offeror’s name)

The following requests information about you. Please provide this information.

This questionnaire was completed by:

Client Name:____________________________________________________________

Title:_________________________________________________________________

Mailing Address (Street and P.O. Box): ______________________________________

City, State, and Zip Code:__________________________________________________

Telephone Number:_______________________________________________________

Email:____________________________________________________________

Date Information Provided:_________________________________________________

Signature:___________________________________ Date:______________________

Part III: Performance Categories, Definitions, and Ratings The Government requests that you make your assessment of the offeror using only the performance assessment descriptions for each of the four performance categories listed below. Use the appropriate assessment shown in the tables below as your entry in the CLIENT ASSESSMENT OF PAST PERFORMANCE table in Part II of this questionnaire.

To ensure consistency, please formulate your performance assessments based upon the assessment definitions table for each performance factor, which are found in the tables below. Select the appropriate assessment by marking an X in the appropriate column in the CLIENT ASSESSMENT OF PAST PERFORMANCE table.

Technical Factor The Technical Factor is used to measure the offeror’s success in the following areas:

1. Technical ability of the staff personnel to perform individual tasks;

1. Technical ability to implement and adhere to concise and well-defined internal organizational operational rules which support mission accomplishment;

1. Technical ability to deal with issues (personnel and technical) in a timely manner while minimizing impact on ongoing operations;

1. Technical ability to perform to the contract requirements; and

1. Technical ability to perform operations so as to reduce program risk.

Management Factor

The Management Factor is used to measure the offeror’s success in the following areas:

1. Ability to hire and retain appropriate staff;

1. Ability to implement and adhere to concise and well-defined internal operational rules;

1. Ability to deal with issues (personnel and technical) in a timely manner while minimizing impact on ongoing operations;

1. Ability to manage to the contract requirements; and

1. Ability to manage risk.

Quality of Service and Improvement Factor The Quality of Service and Improvement Factor is used to measure the offeror’s success in the following areas:

1. Ability to provide/maintain high quality day-to-day service;

1. Ability to prepare the operations for changes associated with growth (additional staff) and/or industry trends (new software releases, security, etc.), including new regulations, policies or instructions in the case of governmental contracts;

1. Ability to analyze existing systems and policies and improve them;

1. Ability to manage risk by following strict change management principles; and

1. Ability to limit negative impact of changes on the enterprise and its users.

Responsiveness to Customer Factor The Responsiveness to Customer Factor is used to measure the offeror’s success in the ability to respond to requests for data (scheduled and ad hoc), analysis, and additional tasks in a timely and appropriate manner.