Past Performance Questionnaire

PAST PERFORMANCE QUESTIONNAIRE HT0014-26-Q-E033

To the Offeror’s Reference:

The Defense Health Agency's Contracting Activity (DHACA), Healthcare Contracting Division Northeast (HCD-NE) is procuring the lease of Hospital Communications Support at Walter National Military Medical Center (WRNMMC). Past Performance is an important part of the evaluation criteria for this acquisition, so your input is very important.

Please complete the following questionnaire to assist this office’s evaluation of the Offeror’s past performance. A typed (preferred) or handwritten response is sufficient. If you need more space than that provided, please attach additional pages.

Please provide an adjectival rating for the evaluation questions below and provide comments to substantiate the assigned rating.

Please complete this form no later than October 26, 2026, by 3:00 PM (EDT) and return it to the company that provided it to you for their submission to this DHA Contracting Office.

Thank you for your assistance in this source selection.

A. EVALUATED CONTRACTOR’S INFORMATION:

Company/Organization Name being evaluated:

Cage Code:

Point of Contact (POC):

Title of POC:

Address:

Telephone Number:

Email address:

B. CONTRACT INFORMATION:

Contract Title/Description:

Contract Number:

Task Order Number (if Applicable):

Status (i.e. On-going, complete):

Annual Contract Value

Total Contract Amount: (Total amount of base period of performance plus any option period(s) exercised to date)

Type of Contract (e.g. FFP, Cost, etc.):

Performance Period being evaluated:

Place of Performance:

Was work with a:

C. CONTRACTING OFFICER REPRESENTATIVE INFORMATION:

COR’s Name:

Telephone Number:

Email:

Evaluated Contractor Performed as:

D. RATING INFORMATION:

RATING

DEFINITION

High Confidence (H)
Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective. Confident (C)
Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with some minor problems for which corrective actions taken by the contractor were effective. Some Confidence (S)
Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.