Evidence-based Technical Assistance for Multistakeholder,
Community-based Quality Collaboratives

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-09-10008, entitled "Evidence-based Technical Assistance for Multistakeholder, Community-based Quality Collaboratives." Past performance is an important part of the evaluation criteria for this acquisition, so input from previous customers of the offeror is extremely important.  This office would greatly appreciate you taking the time to complete this form.  This information is to be provided to Jessica Alderton, the AHRQ Contracting Officer and is NOT to be disclosed to the offeror either verbally or in writing.  Please provide an honest assessment and return to AHRQ (either by mail, fax or E-mail), no later than February 17, 2009, by 12 noon EST. If you have any questions, please contact Jessica Alderton at via E-mail Jessica.Alderton@ahrq.hhs.gov.

Jessica Alderton
Agency for Healthcare Research and Quality
Division of Contracts Management
540 Gaither Road
Rockville, Maryland 20850
FAX: (301) 427-1740

NAME OF OFFEROR:_____________________________________

ADDRESS:_____________________________________________

______________________________________________________

______________________________________________________

Contractor Performance Form

1. Name of Contractor::____________________________________

2. Address:_____________________________________________

______________________________________________________

______________________________________________________

3. Contract/Grant Number: _______________________________________

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

5. Contract/Grant Award Date: _____________________________

6. Contract/Grant 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:_____________________________________________

______________________________________________________

______________________________________________________

CONTRACTOR'S 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 Contractor committed to customer satisfaction? Yes ___ No ___

Would you use this Contractor 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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ATTACHMENT 2

PROPOSAL INTENT RESPONSE SHEET

RFP No. AHRQ-09-10008

Please review the attached request for proposal.  Furnish the information requested below and return this page by January 13, 2009 (12:00 PM ET).  Your expression of intent is not binding but will greatly assist us in planning for the proposal evaluation.

[  ]  INTEND TO SUBMIT A PROPOSAL

[  ] DO NOT INTEND TO SUBMIT A PROPOSAL FOR THE FOLLOWING REASONS:

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

[  ] I GRANT PERMISSION TO THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY, CONTRACTS OFFICE TO ADD THE CONTACT INFORMAION BELOW TO A BIDDERS LIST TO PROVIDE TO OTHER INTERESTED OFFERORS FOR TEAMING/SUBCONTRACING OPPORTUNITIES. (*MUST INCLUDE AUTHORIZED SIGNATURE)

COMPANY/INSTITUTION NAME & ADDRESS:

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

*AUTHORIZED SIGNATURE: __________________________________

TYPED/PRINT NAME AND TITLE: ______________________________

DATE: ___________________

[  ] PLEASE DO NOT RELEASE THE CONTACT INFORMATION.

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Please return to:

Jessica Alderton
Agency for Healthcare Research and Quality
Division of Contracts Management
540 Gaither Road
Rockville, Maryland 20850
Fax; 301-427-1740

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ATTACHMENT 3

BREAKDOWN OF PROPOSED ESTIMATED COST (PLUS FEE) AND LABOR HOURS

INSTRUCTIONS FOR USE OF THE FORMAT

1. Refer to Business Proposal Instructions, Section L of this solicitation. The Instructions contain the requirements for proper submission of cost/price data which must be adhered to.
2. This sample format has been prepared as a universal guideline for all solicitations. It may require amending to meet the specific requirements of this solicitation. For example, this solicitation may require the submission of cost/price data for three years listed on this form. (See Section L, Instructions, Conditions and Notices to Offerors, for the estimated duration of this project.) If this solicitation is phased, identify each phase in addition to each year. Total each year, phase, and sub-element.
3. This format must be used to submit the breakdown of all proposed estimated cost elements. List each cost element and sub-element for direct costs, indirect costs and fee, if applicable. In addition, provide detailed calculations for all items. For example:
   1. For all personnel, list the name, title, rate per hour and number of hours proposed. If a pool of personnel is proposed, list the composition of the pool and how the cost proposed was calculated. List the factor used for prorating Year One and the escalation rate applied between years.
      
      Offeror's proposal should be stated in the same terms as will be used to account for and record direct labor under a contract (i.e. percentage of effort is used for most faculty and professional employees at educational institutions). If percentages of effort are used, the basis to which such percentages are applied must also be submitted by the offeror. The attached format should be revised to accommodate direct labor proposed as a percentage of effort.
      
      
   2. For all materials, supplies, and other direct costs, list all unit prices, etc., to detail how the calculations were made.
   3. For all indirect costs, list the rates applied and the base the rate is applied to.
   4. For all travel, list the specifics for each trip.
   5. For any subcontract proposed, submit a separate breakdown format.
   6. Justification for the need of some cost elements may be listed as an attachment, i.e., special equipment, above average consultant fees, etc.
4. If the Government has provided "uniform pricing assumptions" for this solicitation, the offeror must comply with and identify each item.

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RFP Number:
Organization:
Date:

BREAKDOWN OF PROPOSED ESTIMATED COST (PLUS FEE) AND LABOR HOURS

COST ELEMENT		Option			Option			Total
		Year 1	Year 2	Year 3	Year 1	Year 2	Year 3
DIRECT LABOR:
Labor Category (Title and Name—use additional pages as necessary)	Rate	Hours Amt	Hours Amt	Hours Amt	Hours Amt	Hours Amt	Hours Amt
DIRECT LABOR COST:		$___	$___	$___	$___	$___	$___
MATERIAL COST:		$___	$___	$___	$___	$___	$___
TRAVEL COST:		$___	$___	$___	$___	$___	$___
OTHER (Specify)		$___	$___	$___	$___	$___	$___
OTHER (Specify)		$___	$___	$___	$___	$___	$___
TOTAL DIRECT COST:		$___	$___	$___	$___	$___	$___
FRINGE BENEFIT COST: (if applicable)
% of Direct Labor Cost		$___	$___	$___	$___	$___	$___
INDIRECT COST:
% of Total Direct Cost		$___	$___	$___	$___	$___	$___
TOTAL COST:		$___	$___	$___	$___	$___	$___
FIXED & AWARD FEES: (if applicable)
% of Total Est. Cost		$___	$___	$___	$___	$___	$___
GRAND TOTAL EST COST		$___	$___	$___	$___	$___	$___

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