W91YTZ21R0071_ATTACHMENT TWO_PAST PERFORMANCE QUESTIONNAIRE.rtf

ATTACHMENT 2

PAST PERFORMANCE QUESTIONNAIRE

The Regional Health Contracting Office-Atlantic is conducting a Full and Open Competitive Acquisition. The offeror has identified you as a reference to validate past performance.

Solicitation Number W91YTZ-21-R-0071, is for the non-personal services for Gait Analysis with Markerless Motion Capture Technology for Keller Army Community Hospital, West Point, NY.

Please complete the following questionnaire to assist our evaluation of the contractor’s past performance, and return email no later than 12:00 pm EST on 9 September 2021 to Ingrid Harris at Ingrid.a.harris2.civ@mail.mil.

Name of Contractor being evaluated:

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How long has your company had a contract with this contractor?

Type of service being provided?

Where is the location of this service?

What is the contract amount?

How many FTEs/Studies are being provide on contract?

Have there been late deliveries or other unsatisfactory performance resulting in additional contractual or administrative costs?

Yes No

If “Yes,” explain:

The last three items will discuss schedule performance, quality of service, and customer relations. Please refer to the following Rating System:

Schedule Performance – Please rate overall compliance with reliability and timeliness of scheduled performance.

Exceptional (2) Very Good (3) Satisfactory (4) Marginal (5) Unsatisfactory

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

Quality of Service – Please rate overall compliance with contract statement of work requirement.

(1) Exceptional (2) Very Good (3) Satisfactory (4) Marginal (5) Unsatisfactory

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

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

Exceptional (2) Very Good (3) Satisfactory (4) Marginal (5) Unsatisfactory

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

Exceptional - Performance meets contractual requirements and exceeds many to the contractor’s benefit. The contractual performance of the element being assessed was accomplished with few minor problems for which corrective actions taken were highly effective.

Very Good - Performance meets contractual requirements and exceeds some to the Contractor’s benefit. The contractual performance of the element being assessed was accomplished with some minor problems for which corrective actions taken were effective.

Satisfactory - Performance meets the contractual requirements. The contractual performance of the element being assessed contains some minor problems for which corrective actions taken appear or were satisfactory.

Marginal - Performance does not meet some contractual requirements. The contractual performance of the element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The proposed actions appear only marginally effective or were not fully implemented.

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

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.