EXHIBIT A-5
PAST PERFORMANCE - CLIENT REFERENCE FORM
Respondent Name:
The respondent shall provide a maximum of three (3) separate and verifiable,Non-Agencyclient references, on the following pages. The clients listed must be for work similar in nature to that specified in this solicitation. The same client may not be listed for more than one (1) reference and confidential clients shall not be included. In the event the respondenthas had a name change since the time work was performed for a listed reference, the name under which the respondentoperated at that time must be provided in the space provided for Respondent Name.
The respondent shall include with its Original Response a completed Evaluation Questionnaire for Past Performance (see page 5 below)provided by a maximum of three (3) separate and verifiable, Non-Agencyclient references identified in this Exhibit on pages 2-4 below. The Evaluation Questionnaire for Past Performance must include the dated, original signature of the Non-Agency client reference.Each dated, signed Questionnaire must be provided in anindividual envelope that containstheNon-Agency client reference signature across the sealed flap. The Agency will not accept any Evaluation Questionnaire for Past Performance which is not included with aresponse.
Clients that are listed as subcontractors in the response will not be accepted as Past Performance references under this solicitation. Entities having an affiliation with the respondent(i.e. currently parent, subsidiary having common ownership, having common directors, officers or agents or sharing profits or liabilities) may not be accepted as Past Performance references under this solicitation.
The Agency will consider a maximum of three (3) non-Agency clients who will complete an Evaluation Questionnaire for Past Performance, for evaluation scoring. Responses which do not contain client references will receive a score of zero (0) for the past performance evaluation component.
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
NON-AGENCY
CLIENT REFERENCE #1
Respondent Name:Client’s Name:
Address:
Contract Performance Period:
Location of Services:
Brief description of the services performed by the respondentfor this client:
NON-AGENCY
CLIENT REFERENCE #2
Respondent Name:Client’s Name:
Address:
Contract Performance Period:
Location of Services:
Brief description of the services performed by the respondentfor this client:
NON-AGENCY
CLIENT REFERENCE #3
Respondent Name:Client’s Name:
Address:
Contract Performance Period:
Location of Services:
Brief description of the services performed by the respondentfor this client:
Evaluation Questionnaire for Past Performance
Questions that are not scored according to the rating scale provided, will receive a score of zero (0) for the question.
RespondentName:Non-AgencyClient’s Name:
- Briefly describe the services the respondentperformed for your organization:
- Define the relationship between the respondentand the client reference as one of the following:
Prime Vendor; or
Subcontractor.
Score
- How would you rate the Contract implementation with this respondent?
- How would you rate the respondent’s customer service to clients?
- Did the respondentconsistently meet all of its performance/milestones deadlines?
- Did respondent staff maintain open lines of communication with your organization?
- Did the respondent’s project/contract manager effectively manage the Contract?
- Was the respondent’s staff responsive to technical direction from your organization?
- Did the respondent go beyond the call of duty to resolve urgent issues/concerns expediently?
- Was the respondent’s staff knowledgeable of the Contract requirements and scope of work?
- Was the respondent’s staff knowledgeable of your business rules regarding services?
- Was the respondent proactive in developing/recommending improvements for increasing the efficiency of processes?
- Would you contract with this respondent again?
Total Score:
Past Performance Verified by:
Name (printed) / Title
Signature / Date
AHCA RFP 014-17/18, Attachment A, Exhibit A-5, Page 1 of 5