Department of General Services
Procurement Division
Pharmaceutical Acquisitions Section
Secondary Pharmaceutical Wholesaler
RFP DGS 1106-048
Appendix B
COMPANY REFERENCE FORM
RFP DGS 1106-048
The State of California, Department of General Services (DGS) has received a proposal in
response to a Request for Proposals (RFP DGS 1106-048) for a Secondary Pharmaceutical
Wholesaler.
Company Name (Proposer): [insert name]
We would appreciate your cooperation in completing the attached questionnaire by no later than
November 16, 2011. This questionnaire will be scored as a section of the overall score in our
proposal for California State RFP DGS 1106-048 and will be subject to the Public Records Act.
It is also important to note the due date, as this reference must accompany our bid due to the
State of California no later than November 21, 2011.
Company contact information: [insert name, phone number, e-mail address]
Thank you for taking the time to respond to this important questionnaire.
Please note, this questionnaire will be scored as a section of the overall score for this proposer
and will be subject to the Public Records Act. It is also important to note the due date, as we will
not be able to accept late responses and the proposer will not be notified if the questionnaire is
not returned.
Thank you for taking the time to respond to this important questionnaire. Please contact me by
phone at (916) 375-4565 or e-mail at Rhonda.Kitchen@dgs.ca.gov, if you have additional
questions or concerns.
Thank you,
Rhonda Kitchen
Health Program Specialist
Procurement Division, Pharmaceutical Acquisitions Section
Department of General Services
Rater’s Name/Person Responding:
Title/Position:
Phone Number: (
)
Fax Number: (
)
E-mail:
Signature of Rater: 
10/31/2011
Date:
Page 1 of 3
Department of General Services
Procurement Division
Pharmaceutical Acquisitions Section
Secondary Pharmaceutical Wholesaler
RFP DGS 1106-048
Appendix B
Dollar Amount of Contract with Reference Organization: $
Contract Period:
Types of Products/Services Provided:
Please rate the following 10 questions on the .04 point scale used as guidelines below:
Excellent (5) – Performance met all contract requirements and exceeded many to the
agency’s benefit. No problems were encountered.
Good (4) – Performance met all contract requirements and exceeded some to the
agency’s benefit. There were a few minor problems, which were negligible.
Average (3) – Performance met contract requirements. There were some minor
problems and corrective actions taken by the contractor were acceptable.
Below Average (2) – Performance did not meet the contractual requirements. There
were some problems of a serious nature for which corrective action was only somewhat
effective.
Poor (1) – Performance did not meet contractual requirements. There were serious
problems and the contractor’s corrective actions were ineffective.
If you rate 1, 2, or 3 for any question, please provide a reason in the appropriate
comments column.
Factors Rated
Product Ordering
Comments:
Delivery Timeliness
Comments:
Product
Availability /
Quality
Comments:
Customer Service
Related Questions
How would you rate the ease of use of
the contractor’s ordering systems?
1. How would you rate the timeliness
and accuracy of pharmaceutical
deliveries by the contractor?
2. How would you rate ability of
contractor to provide needed
pharmaceuticals and the quality of
the products provided?
3. How would you rate the quality of
customer service and telephone
response provided by the contractor?
Comments:
10/31/2011
Page 2 of 3
Rating
(Check One)
5 4 3 2 1
5 4 3 2 1
5 4 3 2 1
5 4 3 2 1
Department of General Services
Procurement Division
Pharmaceutical Acquisitions Section
Secondary Pharmaceutical Wholesaler
RFP DGS 1106-048
Appendix B
Account
Management
Comments:
Account
Management
Comments:
Reporting
Comments:
Reporting
Comments:
Implementation
Comments:
Customer
Satisfaction
4. How would you rate the contractor’s
ability to adhere to agreed upon
performance reviews, meeting
schedules and the usefulness of
these meetings and their ability to
produce positive outcomes?
5. How would you rate the level of
turnover of the account management
team and their ability to resolve
problems?
5 4 3 2 1
6. How would you rate the contractor’s
ability to impart training and technical
support for reporting systems?
5 4 3 2 1
7. How would you rate the contractor’s
ability to meet reporting services as
promised in your contract and
timeliness of delivering reports?
5 4 3 2 1
8. How would you rate your level of
satisfaction with the contractor’s
implementation process in terms of
thoroughness, ease of transition and
timeliness?
9. How would you rate your
willingness/interest to work with this
contractor again, based on prior
experiences and your overall
satisfaction with the contractor?
Comments:
10/31/2011
5 4 3 2 1
Page 3 of 3
5 4 3 2 1
5 4 3 2 1