Incorporating Health Information Technology Into Workflow Redesign

ATTACHMENT 1

PAST PERFORMANCE QUESTIONNAIRE

PART ONE: INSTRUCTIONS

The offeror listed below has submitted a proposal in response to the Agency for Healthcare Research and Quality (AHRQ) Solicitation No. AHRQ-08-10036, entitled "Incorporating Health IT into Workflow Redesign." Past performance is an important part of the evaluation criteria for this acquisition, so input from previous customers of the offeror is important.  This office would greatly appreciate you taking the time to complete this form.  This information is to be provided to Linda Simpson, the AHRQ Contract Specialist, and is NOT to be disclosed to the offeror either verbally or in writing.  Please provide an honest assessment and return to AHRQ to the address shown below, no later than August 29, 2008, 12 noon EST

Agency for Healthcare Research and Quality
Division of Contracts Management
Attn:  Linda Simpson, Contract Specialist
540 Gaither Road
Rockville, Maryland 20850
FAX: (301) 427-1740

If you have any questions, please contact the Contract Specialist via E-mail at Linda.Simpson@ahrq.hhs.gov.

NAME OF OFFEROR:_____________________________________

ADDRESS:_____________________________________________

______________________________________________________

______________________________________________________

Performance Form

1. Name of Organization:____________________________________

2. Address:_____________________________________________

______________________________________________________

______________________________________________________

3. Contract/Grant Number (if relevant): _______________________________________

4. Contract/Grant Value (Base Plus Options) (if relevant): ________________________

5. Contract/Grant Award or Project Beginning Date: _____________________________

6. Contract/Grant/Project Completion Date: ________________________________

7. Type of Contract/Grant/Project: (Check all that apply) ( )FP ( )FPI ( )FP-EPA

( ) Award Fee ( ) CPFF-Completion ( ) CPFF-Term ( ) CPIF ( ) CPAF

( ) IO/IQ ( ) BOA ( ) Requirements ( ) Labor-Hour ( )T&M ( ) SBSA

( )8(a) ( )SBIR ( ) Sealed Bid( )Negotiated( )Competitive ( )Non-Competitive

( ) Other __________________________

8. Description of Requirement:_____________________________________________

______________________________________________________

______________________________________________________

PERFORMANCE RATING

Ratings: Summarize performance and circle in the column on the right the number which corresponds to the performance rating for each rating category.  Please select for explanation of rating scale.

Category	Comments	Rating Scale
Quality of Product or Service	Comments	0
		1
		2
		3
		4
		5
Cost Control	Comments	0
		1
		2
		3
		4
		5
Timeliness of Performance	Comments	0
		1
		2
		3
		4
		5
Business Relations	Comments	0
		1
		2
		3
		4
		5

Customer Satisfaction—Is/was the organization committed to customer satisfaction? Yes ___ No ___

Would you use this organization again? Yes ___ No ___

Reason: ________________________________________

NAME OF EVALUATOR: ________________________________________
(Please Print)

TITLE OF EVALUATOR: ________________________________________

SIGNATURE OF EVALUATOR:___________________________________

DATE:_____________________

MAILING ADDRESS: Include name of organization/Federal agency

________________________________________________________

________________________________________________________

________________________________________________________

PHONE #:__________________________________

E-MAIL:__________________________________

Rating Guidelines:   Summarize performance in each of the rating areas. Assign each area a rating 0(Unsatisfactory), 1(Poor), 2(Fair),  3(Good),  4(Excellent)  5(Outstanding).  Use the following instructions as guidance in making these evaluations.

Rating Scale	Quality	Cost Control	Timeliness of Performance	Business Relation
	-Compliance with contract requirements -Accuracy of reports -Technical excellence	-Within budget (over/ under target costs) -Current, accurate, and complete billings -Relationship of negotiated costs to actual -Cost efficiencies -Change orders issue	-Met interim milestones -Reliable -Responsive to technical direction -Completed on time, including wrap-up and project adm -No liquidated damages assessed	-Effective management -Businesslike correspondence -Responsive to project requirements -Prompt notification of problems -Reasonable/cooperative -Flexible -Pro-active -Effective small/small disadvantaged business sub-contracting program
0-unsatisfactory	Nonconformances are jeopardizing the achievement of project requirements, despite use of Agency resources	Ability to manage cost issues is jeopardizing performance of project requirements, despite use of Agency resources	Delays are jeopardizing the achievement of project requirements. despite use of Agency's resources	Response to inquiries, technical/service/administrative issues is not effective
1-Poor	Overall compliance requires major Agency resources to ensure achievement of project requirements	Ability to manage cost issues requires major Agency resources to ensure achievement of project requirements	Delays require major Agency resources to ensure achievement of project requirements	Response to inquiries, technical/service/administrative  issues is marginally effective
2-Fair	Overall compliance requires minor Agency resources to ensure achievement of project requirements	Ability to manage cost issues requires minor Agency resources to ensure achievement of project requirements	Delays require minor Agency resources to ensure achievement of project requirements	Response to inquiries, technical/service/administrative issues is somewhat effective
3-Good	Overall compliance does not impact achievement of project requirements	Management of cost issues does not impact achievement of project requirements	Delays do not impact achievement of project requirements	Response to inquiries, technical/service/administrative issues is usually effective
4-Excellent	There are no quality problems	There are no cost management issues	There are no delays	Response to inquiries, technical/service/administrative issues is effective
5-Outstanding	The organization has demonstrated an outstanding performance level that justifies adding a point to the score.  It is expected that this rating will be used in those rare circumstances where organization performance clearly exceeds the performance levels described as "Excellent."

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