Attachment 2: Past Performance Questionnaire

PAST PERFORMANCE QUESTIONNAIRE

The Medical Acquisition Support Office – Omega (MASO-O) is conducting a competitive acquisition for Ground Ambulance Services at Fort Polk, LA. The offeror has identified you as a reference to validate past performance.

Please complete the following questionnaire to assist our evaluation of the Contractor’s past performance and return via email no later than 21 October 2026, 8:00 AM/CDT to [email protected] and [email protected].

RESPONDENT INFORMATION:

Contracting Activity/Customer:

Point of Contact (POC):

Title of POC:

Telephone:

Email:

OFFEROR’S REFERENCE INFORMATION:

Contractor Name:

Point of Contact (POC):

Telephone Number:

Email:

CONTRACT INFORMATION:

Contract Number:

Task Order Number:

Type of Contract:

Performance Period: (Base plus any options):

Total Contract Dollar Value:

Description of Services:

Please refer to the following assessment definitions to assess the Contractor’s performance in each of the areas listed in this questionnaire: -914401016000
(E) Exceptional - The Contractor’s performance meets contractual requirements and exceeds many (requirements) to the Government’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the Contractor were highly effective.

(V) Very Good - The Contractor’s performance meets contractual requirements and exceeds some (requirements) to the Government’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the Contractor were effective.

(S) Satisfactory - The Contractor’s performance meets contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the Contractor appear or were resolved satisfactorily.

(M) Marginal - Performance does not meet some contractual requirements. The contractual performance reflects a serious problem for which the Contractor has not yet identified corrective actions or the Contractor’s proposed actions appear only marginally effective or were not fully implemented.

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

(N) Not Applicable – Unable to assess the area.

Quality
Assess how the Contractor:
E
V
S
M
U
NA
Conformed to contract or order requirements, specifications and standards of good workmanship (e.g., commonly accepted technical, professional, environmental, or safety and health standards).