Attachment VII: Proposer Reference Questionnaire

Attachment VII: Proposer Reference Questionnaire

RFP#3000003817

PROPOSALREFERENCEQUESTIONNAIRE

REFERENCESUBJECT:Click here to enter text.

The“referencesubject”specifiedabove,intendstosubmitaproposaltotheLouisianaDepartmentof HealthHospitals(DHH)inresponsetotheRequestforProposals(RFP)indicatedforIndependent Verification & Validation Services.Asapartof suchproposal,thereference subject mustincludeanumberofcompletedandsealedreference questionnaires(usingthisform).

Eachindividualrespondingtothisreferencequestionnaireis askedtofollowtheseinstructions:

• completethis questionnaire(eitherusingtheform providedoran exactduplicateof thisdocument);
• signanddatethecompletedquestionnaire;
• sealthecompleted,signed,anddatedquestionnairein anewstandard#10envelope;
• signin ink acrossthesealedportionof theenvelope;and
• returnthesealedenvelopecontainingthecompletedquestionnairedirectlytothereferencesubject.

1. Whatisthenameoftheindividual,company,organization,orentityrespondingtothis referencequestionnaire?

1. Pleaseprovidethefollowinginformationabouttheindividualcompletingthisreference questionnaireonbehalfoftheabove-namedindividual,company,organization,orentity.

NAME: / Click here to enter text. /
TITLE: / Click here to enter text. /
TELEPHONE: / Click here to enter text. /
E-MAILADDRESS: / Click here to enter text. /

1. Whatservicesdoes/didthereferencesubjectprovidetoyourcompanyororganization?

1. Whatisthelevelofyouroverallsatisfactionwiththereferencesubjectasavendorofthe servicesdescribedabove?

Pleaserespondbycheckingtheappropriatenumberonthescalebelow.

☐1 – Least Satisfied

☐2

☐3

☐4

☐5 – Most Satisfied

Ifyouchecked 3orlessabove,whatcouldthereference subjecthavedonetoimprove that rating?

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1. Iftheservicesthatthereferencesubjectprovidedtoyourcompanyororganizationare completed, weretheservicescompletedincompliancewiththetermsofthecontract,on time,andwithinbudget?Ifnot,pleaseexplain.

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1. Ifthereferencesubjectisstillprovidingservicestoyourcompanyororganization,are theseservicesbeingprovidedincompliance withthetermsofthecontract,ontime,and withinbudget?Ifnot,pleaseexplain.

1. Howsatisfiedareyouwiththereferencesubject’sability toperformbasedonyour expectationsandaccordingtothecontractualarrangements?

1. Inwhatareasofservicedeliverydoes/didthe referencesubjectexcel?

1. Inwhatareasofservicedeliverydoes/didthe referencesubjectfallshort?

1. Whatisthelevelofyoursatisfaction withthereferencesubject’s projectmanagement structures,processes,andpersonnel?

Pleaserespondbycheckingtheappropriatenumberonthescalebelow.

☐1 – Least Satisfied

☐2

☐3

☐4

☐5 – Most Satisfied

What,ifany,commentsdoyouhaveregardingthescoreselectedabove?

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1. Consideringthestaffassignedbythereferencesubjecttodelivertheservicesdescribed inresponse toquestion3above,howsatisfiedareyouwiththetechnicalabilities, professionalism,andinterpersonalskillsoftheindividualsassigned?

Pleaserespondbycheckingtheappropriatenumberonthescalebelow.

☐1 – Least Satisfied

☐2

☐3

☐4

☐5 – Most Satisfied

What,ifany,commentsdoyouhaveregardingthescoreselectedabove?

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1. Wouldyoucontractagainwiththereferencesubjectforthesameorsimilarservices?

Pleaserespondbycheckingtheappropriatenumberonthescalebelow.

☐1 – Least Satisfied

☐2

☐3

☐4

☐5 – Most Satisfied

What,ifany,commentsdoyouhaveregardingthescoreselectedabove?

Click here to enter text.

REFERENCE SIGNATURE: ______

*by the individual completing this requestforreferenceinformation

*mustbethesameasthesignatureacrosstheenvelopeseal

DATE: ______