ATTACHMENT F
PAST PERFORMANCE - CLIENT REFERENCE FORM
Vendor’s Name:
In the spaces provided below, the Respondent shall list all names under which it has operated during the past
five (5) years (January 4, 2011).
The respondents shall provide a maximum of three (3) separate and verifiable, Non-Agency client references,
on the following pages. The Respondent shall provide the information indicated for a maximum of three (3)
separate and verifiable, Non-Agency clients. 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 Respondent has had a name change since the time work was
performed for a listed reference, the name under which the Respondent operated at that time must be provided
in the space provided for Vendor’s Name.
The Respondent shall include with its response a completed, signed with original signature and dated
Evaluation Questionnaire for Past Performance, provided by a maximum of three (3) Non-Agency identified (in
this Attachment) client references, in individual envelopes that contain a client signature across the sealed flap.
The Agency will not accept any Evaluation Questionnaire for Past Performance which is not included with a
prospective Vendor’s response.
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) 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.
The Agency reserves the right to contact references other than those identified by the Respondent to
obtain additional information regarding past performance. Any information obtained as a result of
such contact may be used to determine whether or not the Respondent is a “responsible vendor”, as
defined in section 287.012(25), Florida Statutes.
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AHCA RFP 004-15/16, Attachment F, Page 1 of 6
QUESTIONS CONTAINED ON THE EVALUATION QUESTIONNAIRE FOR PAST PERFORMANCE THAT
ARE NOT SCORED ACCORDING TO THE RATING SCALE PROVIDED, WILL RECEIVE A SCORE OF
ZERO (0) FOR THE QUESTION.
THE FORM MAY NOT BE RETYPED AND/OR MODIFIED AND MUST BE SUBMITTED IN THE ORIGINAL
FORMAT. ANY CAVEAT(S) AND/OR MODIFICATION(S) TO ATTACHMENT F, PAST PERFORMANCE –
CLIENT REFERENCE FORM WILL RESULT IN THE REJECTION OF A PROSPECTIVE VENDOR’S
RESPONSE. FAILURE TO SUBMIT PAGE 1 OF ATTACHMENT F, PAST PERFORMANCE – CLIENT
REFERENCE FORM WILL RESULT IN THE REJECTION OF A PROSPECTIVE VENDOR’S RESPONSE.
ATTACHMENT F, PAST PERFORMANCE – CLIENT REFERENCE FORM IS AVAILABLE FOR
RESPONDENTS TO DOWNLOAD AT:
HTTP://AHCA.MYFLORIDA.COM/PROCUREMENTS/INDEX.SHTML.
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AHCA RFP 004-15/16, Attachment F, Page 2 of 6
NON-AGENCY
CLIENT REFERENCE #1
Vendor’s Name:
Client’s Name:
Address:
Contract Performance Period:
Location of Services:
Brief description of the services performed by the Respondent for this client:
AHCA RFP 004-15/16, Attachment F, Page 3 of 6
NON-AGENCY
CLIENT REFERENCE #2
Vendor’s Name:
Client’s Name:
Address:
Contract Performance Period:
Location of Services:
Brief description of the services performed by the Respondent for this client:
AHCA RFP 004-15/16, Attachment F, Page 4 of 6
NON-AGENCY
CLIENT REFERENCE #3
Vendor’s Name:
Client’s Name:
Address:
Contract Performance Period:
Location of Services:
Brief description of the services performed by the Respondent for this client:
AHCA RFP 004-15/16, Attachment F, Page 5 of 6
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.
Vendor’s Name:
Non-Agency Client’s Name:
1.
Briefly describe the services the Vendor performed for your organization:
2.
Define the relationship between the Vendor and the client reference as one of the following:
(circle one)
Prime Vendor; or
Subcontractor.
Score
3.
How would you rate the Contract implementation with this Vendor?
(Excellent = 5; Good = 4; Acceptable = 3; Fair = 2; Poor = 1)
4.
How would you rate the Vendor’s customer service to clients?
(Excellent = 5; Good = 4; Acceptable = 3; Fair = 2; Poor = 1)
5.
Did the Vendor consistently meet all of its performance/milestones deadlines?
(Yes = 5; No = 0)
6.
Did Vendor staff maintain open lines of communication with your organization?
(Yes = 5; No = 0)
7.
Did the Vendor’s project/contract manager effectively manage the Contract?
(Yes = 5; No = 0)
8.
Was the Vendor’s staff responsive to technical direction from your organization?
(Yes = 5; No = 0)
9.
Did the Vendor go beyond the call of duty to resolve urgent issues/concerns expediently?
(Yes = 5; No = 0)
10.
Was the Vendor’s staff knowledgeable of the Contract requirements and scope of work?
(Yes = 5; No = 0)
11.
Was the Vendor’s staff knowledgeable of your business rules regarding services?
(Yes = 5; No = 0)
12.
Was the Vendor proactive in developing/recommending improvements for increasing the efficiency of
processes?
(Yes = 5; No = 0)
13.
Would you contract with this Vendor again?
(Yes = 5; No = 0)
Total Score:
Past Performance Verified by:
Name (printed)
Title
Signature
Date
AHCA RFP 004-15/16, Attachment F, Page 6 of 6