EXHIBIT_C_Package_Information_and_Forms.doc

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IL ARNG Medical Case Management
Solicitation number
W91SMC-15-R-0003
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Exhibit C to Solicitation W91SMC-15-R-0003

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MEDICAL CASE MANAGEMENT SERVICES

RFP W91SMC-15-R-0003

EXHIBIT C PACKAGE INFORMATION AND FORMS

Instructions to Offeror for sending Reference Questionnaire Forms: Prepare and submit to the owners of the projects listed in your Exhibit A “Performance Relevancy Questionnaires”, a Reference Package (Exhibit C). For Government contracts, send to Contracting Officer or Technical Representative. For commercial references send to personnel with duties similar to those for Government contracts. Offerors should follow-up and encourage references to get the questionnaires to the Contracting Officer in a timely manner. If you have multiple references at one location (Base etc.), send one cover letter and questionnaire for each contract you want a reference for. Your questionnaire package should contain the following:

Cover Letter (See SAMPLE) (Exhibit C1)

Respondent Info Rating Sheets (Exhibit C2)(the next 5 pages) - Offeror should put name in spaces indicated and ensure it is on every page for identification purposes.

Suggested - Pre Addressed stamped envelope to return to Contracting Officer.

OFFEROR SHOULD PLACE THEIR NAME ON TOP OF EACH QUESTIONNAIRE PAGE!!!

OFFEROR SHOULD DELETE THESE INSTRUCTIONS BEFORE SENDING OUT QUESTIONNAIRES

EXHIBIT C1

SAMPLE TRANSMITTAL LETTERAND PAST PERFORMANCE EVALUATION QUESTIONNAIRE

Your Company Letterhead

Date: _________________

To: ______________________________________

We have listed your firm as a reference for the work we have performed for you as listed below. Our firm has submitted a proposal under a project advertised by the USPFO-IL. In accordance with Federal Acquisition Regulations (FAR), they will evaluate our firm's past performance. Your candid response to the attached questionnaire will assist the evaluation team in this process. We understand that you have a busy schedule and your participation in this evaluation is greatly appreciated. Please complete the enclosed questionnaire as thoroughly as possible. Space is provided for comments. A completed CPARS Evaluation for a DoD project or similar Agency appraisal form may be substituted for this reference questionnaire. Understand that while the responses to this questionnaire may be released to the offeror, FAR 15.306 (e)(4) prohibits the release of the names of the persons providing the responses. Complete confidentiality will be maintained. Only one response from each office is required.

Please send your completed questionnaire to the following address to arrive NOT LATER THAN 2:00 pm CDT May 18, 2015. Do not return them to our company.

Send by email to:

CPT Paul Seivert at paul.m.seivert.mil@mail.mil

-OR-

Send by mail to:

USPFO-IL P&C

Attn: CPT Paul Seivert

1301 N. MacArthur Blvd.

Springfield, IL 62702-2317

If you have questions regarding the attached questionnaire, or require assistance, please contact CPT Paul Seivert at (217) 761-3551 or email paul.m.seivert.mil@mail.mil. Thank you for your assistance. E-Mail is preferred.

Signature and Title

RATING DESCRIPTIONS: Use the following descriptions as guidance in providing ratings.

RATING
DEFINITION
Outstandting (O)
Indicates the contractor’s performance record within the area of evaluation Exceeded that required by the contract.
Above Average (AA)
Indicates the contractor’s performance record within the area of evaluation Met All contractual requirements.
Satisfactory (S)
Indicates the contractor’s performance record within the area of evaluation Met Essentially All contractual requirements.
Marginal (M)
Indicates the contractor’s performance record within the area of evaluation Met Some of the contractual requirements. However, changes to the contractor’s existing processes may be necessary in order to achieve contract requirements.
Unsatisfactory (U)
Indicates the contractor’s performance record within the area of evaluation Failed to Meet the minimum Government requirements.
Unknown or Not Applicable (N/A)
The question does not apply. No performance record identifiable within the area of evaluation.

To obtain an electronic version of the form please contact: CPT Paul Seivert at (217) 761-3551 or paul.m.seivert.mil@mail.mil.

THE QUESTIONNAIRE SHOULD BE SUBMITTED BY THE FOLLOWING MEANS:

Return via email to the email address shown above. Forms may be mailed to USPFO-IL P&C Attn: CPT Paul Seivert 1301 N. MacArthur Blvd. Springfield, IL 62702-2317.

Mark cover sheet: (Attention: RFP W91SMC-15-R-0003 “Source Selection Sensitive Information”)

SOURCE SELECTION SENSITIVE WHEN COMPLETED

*****NOT TO BE RELEASED OUTSIDE GOVERNMENT CHANNELS*****

(Exhibit C2) RESPONDENT IDENTIFICATION AND RATINGS

(Part 1 Contractor submitting Proposal fill-in)

Reference is provided for: ____________________________________

Contract Number or Project Title______________________________________________________

Date of Award/Completion Date______________________________________________________

Location_________________________________________________________________________

Dollar Amount____________________________________________________________________

Brief Description of work and your role in the referenced contract: ___________________________

(Part 2 Person providing Reference) Reference is provided by: ___________________________

Company/Agency: _________________________________________________________________

Business Address; ________________________________________________________________

Telephone Number: _______________________________________________________________

E-Mail Address: __________________________________________________________________

Relationship to Contract: ___________________________________________________________

If information above (Part 1) is not accurate, please indicate.

OFFEROR Name___________________________

SOURCE SELECTION SENSITIVE WHEN COMPLETED

Please circle the appropriate rating.

(1) How responsive was the contractor’s quality program in identifying, correcting, and preventing initial and recurring contract discrepancies?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(2) How complete were the contractor’s quality procedures and how well did employees follow them?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(3) Adequacy of medical case management services/supplies/personnel. Were the medical case management services/supplies/personnel provided by the contractor adequate and relevant to the required effort?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(4) Overall, how would you rate the quality of medical case management services provided for this project?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(5) Rate timeliness in meeting requirements and adhering to deadlines and/or time limitations (delivery/performance), taking into account all excusable delays. Was the project completed in a timely manner?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(6) Did the contractor provide timely notices of delays and timely status to Government?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(7) How well did the contractor manage the project, in terms of accurate and timely execution of medical case management services, timely payment of subcontracts, and general business practices?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

OFFEROR Name______________________

(8) Rate how well subcontractors/employees were managed and work coordinated. Explain in remarks any subcontracting issues (positive or negative) that impacted the performance of your contract.
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(9) Rate the timeliness and quality of the contractor’s submission of required documents/ reports. Please specify any use of the medical information systems specified in the Performance Work Statement (if applicable).
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(10) Did the contractor provide adequate, competent and qualified management, key personnel and technical personnel capable of meeting contract requirements throughout the performance period of the contract?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(11) How well did the contractor work independent of Government guidance, oversight and assistance?
O
AA
S
M
U
NA

REMARKS:_____________________________________________________________________________________

(12) How effectively did your contractor’s key management personnel support the initial contract startup, management of contingency situations, and respond to problems and changes?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(13) Was the Event manager always present on site when work was performed?
O
AA
S
M
U
NA

REMARKS: _____________________________________________________________________________________

(14) How timely and effective were the contractor’s responses to and resolution of technical problems? Did the Event manager have sufficient authority to make decisions or take actions during project performance?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(15) Overall, how would you rate this contractor’s business practices, customer relationship, and ability to successfully perform? Did the contractor demonstrate a reasonable and cooperative business relationship with the Government’s contract management personnel?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(16) How effective was the contractor’s safety program to ensure compliance with federal, state and local regulations? Did the contractor implement and follow their safety plan? Did they run a “safe” jobsite?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(17) How well did the contractor comply with applicable laws and regulations such as OSHA, AR 40-501 Standards of Medical Fitness (if applicable), AR 40-35 Dental Readiness & Community Oral Health Protection (if applicable), Service Contract Act of 1965, and applicable local/state/federal laws?
O
AA
S
M
U
NA

REMARKS: _________________________________________________________________________

(18) How well did the contractor comply with Utilization of Small Business Concerns requirements?
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(19) How innovative was the contractor in performing the technical aspects of this contract and resolving problems? How well did the contractor respond to and act on customer feedback? (Customer Satisfaction)
O
AA
S
M
U
NA

REMARKS: ____________________________________________________________________________________

(20) How would you rate the Contractor’s overall performance?
O
AA
S
M
U
NA

REMARKS:

(21) What were the contractor’s top documented strengths, if any, in performing the contract requirements?

REMARKS: ____________________________________________________________________________________

(22) What were the contractor’s top documented weaknesses, if any, in performing the contract requirements?

REMARKS: ____________________________________________________________________________________

(23) Please Provide Any Additional Information You Feel Is Important Not Covered Elsewhere:

REMARKS: ____________________________________________________________________________________

Thank you for your remarks. Please ensure that you return this questionnaire to the Contracting Agency. Do NOT return to the evaluated contractor.

NAME OF PERSON SUBMITTING REFERENCE

DATE_____________________

Contact Phone Number:____________________________

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