Past_Performance_Questionnaire.pdf

SOURCE SELECTION INFORMATION–(SEE FAR 3.104)

FOR OFFICIAL USE ONLY

RFP No. W91YTZ-18-R-0025

PAST PERFORMANCE QUESTIONNAIRE

DEPARTMENT OF THE ARMY

United States Army Medical Command

Health Care Acquisition Activity 4-2817 Riley Road

Fort Bragg, NC 28310

Fort Bragg Cell

MCXC--CT

SUBJECT: Offeror Past Performance Assessment in Support of Solicitation Number W91YTZ-18-R-0025

Dear Sir/Ma’am;

The US Army Medical Command is currently conducting a competitive source selection to evaluate offerors on subject solicitation. As part of this evaluation, we have requested that the offerors provide information about their past performance on same or similar federal, state or local government or commercial contracts as compared to North American Industry Classification System (NAICS) 541990.

You have been identified as the point of contact cited on the enclosure.

Your assessment of their performance is extremely valuable to our evaluation. Please complete the enclosure and return to the Fort Bragg Cell 4-2817 Riley Road, Fort Bragg, NC 28310. Contracting must be in receipt of the questionnaire no later than 5pm EST, 9 August 2018. Your questionnaire may be submitted electronically to, Ms. Donna L. Blossom, donna.l.blossom.civ@mail.mil AND the Contracting Officer, Ms. Cheryl A. Ricker at cheryl.a.ricker.civ@mail.mil.

PAST PERFORMANCE EVALUATION QUESTIONNAIRE FORM

Contractor:____________________ Contract No.:____________________________

Subcontract No. (if applicable):_________________________________

POC:________________________ Title:________________________ (Name) (E.G. PCO/ACO/TM)

(Agency, Telephone No., E-mail Address & Fax Number)

The following questions pertain to the contractor’s record of past (within the past three years) and current performance. The information that you provide will be used in the awarding of a federal contract. Therefore, it is important that our information be as factual and accurate as possible. Please provide examples and/or explanations (use additional pages if necessary). The following adjectival ratings shall be used in your response.

Outstanding: Performance meets contractual requirements and exceeds many requirements that benefit the end user. Work was accomplished with few, if any, minor problems for which corrective actions taken by the contractor were highly effective.

Good: Performance meets contractual requirements and exceeds some requirements that benefit the end user. Work was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Acceptable: Performance meets contractual requirements. Work was accomplished with some minor problems for which corrective actions taken by the contractor were satisfactory.

Marginal: Performance does not meet some contractual requirements. Serious problems with contractor performance were experienced for which the contractor has either not yet identified corrective actions or the corrective actions taken appear only marginally effective.

Unacceptable: Performance does not meet most contractual requirements. Serious problems with contractor performance were experienced for which the corrective actions were ineffective.

In addition to the above rating please access the Risk Factor as defined below.

High Risk (H) - Verification of past performance shows that offerors have consistently not met work schedules and other obligations, have defaulted on at least one contract within the past three years, or have chronically failed to meet contract terms.

Medium Risk (M) - Verification of past performance shows that offeror meets work schedules and specified services most of the time, meets contract terms without failure or resolves issues immediately, and has not been defaulted on any contract within the past three years.

Low Risk (L) - Verification of past performance shows that offeror consistently meets work schedules, provides specified services, meets contract terms without failure, and has not been defaulted on any contract within the past three years.

Neutral / Unknown Performance Risk (N). No record of past performance.

PART I. (To be completed by the Offeror)

A. CONTRACT IDENTIFICATION

Contractor/Company Name/Division:

Address:

Program Identification/Title:

Contract Number:

Contract Type:

Prime Contractor Name (if different from the contractor name cited above):

Contract Award Date:

Forecasted or Actual Contract Completion Date:

Nature of the Contractual Effort or Items Purchased:

B. IDENTIFICATION OF OFFEROR’S REPRESENTATIVE

Name:

Title:

Date:

Telephone Number:

Address:

E-mail Address:

PART II. EVALUATION (To be completed by Point of Contact – Respondent)

PAST PERFORMANCE SURVEY QUESTIONNAIRE – Attachment

Hello:

The offeror has identified you as a reference to validate the offeror’s past performance. Past Performance is an important part of the evaluation criteria for this acquisition, so your input is very important. Please respond no later than the close of the solicitation date and time to Ms. Donna Blossom, donna.l.blossom.civ@mail.mil.

Handwritten responses are sufficient. If you need more space than that provided, please attach additional pages. If contractor has held more than one contract with you, please note the information. Responses will be treated as "source selection sensitive information."

Contract Identification:

A. CONTRACTOR: ________________________________________________________

CONTRACT NUMBER: __________________________________________________

DELIVERY ORDER(s) (if applicable) _______________________________________

PERIOD OF PERFORMANCE:

__________________________ OPTIONS_________

TOTAL CONTRACT AMOUNT: $______________________________________________

DESCRIBE SERVICES acquired. Please include number and type of providers:

____________Competed? ___ Yes ___ No

Type of Contract: Negotiated ________ Sealed Bid ________ Fixed Price ________

Other (specify) _________

Complexity of Work: __________ Difficult Routine _____________

Explain: ______________________________________________________________________ mailto:donna.l.blossom.civ@mail.mil

B. Please provide name, title, address and phone number of the person completing this questionnaire.

Name___________________________________________________________________

Title ________________________________________________________________________

Company/Government Address ___________________________________________________________

Phone: ______________________ Ext # ______________

Email Address:

Is there anyone else we should send this questionnaire to? Please identify by name, organization and phone number.

Past Performance Survey Questionnaire

C. ASSESSMENT ELEMENTS. The following begins the survey questionnaire on Offeror’s (Contractor) performance. Based on definitions at the end of the questionnaire, please assess offeror's performance regarding:

Offeror: _____________________________________Contract Number__________________________

1. Quality of Service. Assess the offeror's conformance to contract requirements, specifications, and standards of good workmanship. Did the service meet the required level of quality.

Performance Rating _______________________ Risk Factor Rating (H) (M) (L) (U)

Reason _____________________________________________________________

2. Schedule. Assess the offeror's adherence to contract schedules, including administrative aspects of performance, timeliness of completion of the contract, milestones, delivery schedules, administrative requirements.

Performance Rating _______________________ Risk Factor Rating (H) (M) (L) (U)

3. Business Relations. Assess the integration and coordination of all activity needed to execute the contract, specifically the timeliness, anticipation of problems, completeness and quality of problem identification, corrective action plans, the offeror's history of reasonable and cooperative behavior in resolving issues, commitment to customer satisfaction, and management of subcontracts (if any).

Performance Rating _______________________ Risk Factor Rating (H) (M) (L) (U)

4. Key Personnel. Assess the offeror's performance, experience in management, in retaining, supporting, and replacing, when necessary, key personnel.

Performance Rating _______________________ Risk Factor Rating (H) (M) (L) (U)

5. Offeror's Cost Control. Did the contractor deliver at the agreed-to price/cost? Describe the reasons for changes to contract value (e.g., scope changes, overrun/under run, government-imposed schedule changes, etc.)

Performance Rating _______________________ Risk Factor Rating (H) (M) (L) (U)

Reason _________________________________________________________________

6. Any reservations about recommending a future contract award to this offeror? No ___ Yes___, Why?

(good business relations, very organized, very responsive, etc.)