36A79720Q0007-005.pdf

ATTACHMENT 4: PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for High Tech Medical Equipment (HTME) Acceptance Testing Services for the Department of Veterans Affairs’ National Acquisition Center (NAC), High-Tech Medical Equipment Ordering Division located in Hines, IL.

PAST PERFORMANCE INSTRUCTIONS

The National Acquisition Center (NAC) located in Hines, IL has issued a solicitation for inspection services on newly installed HTME systems at VA campuses nation-wide. These systems include, but are not limited to, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Single Photon Emission Computed Tomography (SPECT).

Past performance information will be used to evaluate quotations received. Section A is to be completed by the Quoter. Section A of the enclosed questionnaire lists the quoter who has identified your office/business as a source to evaluate their past performance. Section A also authorizes release of this information to the NAC.

The Quoter must provide this entire document to each of its assessors. The Quoter shall only submit with its quotation (by the closing date of the Solicitation) copies of Section A of the questionnaire as provided to the assessors.

Section B, in its entirety, is to be completed by the assessor(s). An individual assessor knowledgeable of the contractor’s quality of services rendered is requested to verify dates and description of services rendered, complete the questionnaire, and submit to the Contracting Officer. If evaluating more than one contract for the same contractor, use a separate questionnaire for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing your assessment is greatly appreciated. The questionnaire should be completed as soon as possible but not later than January 17, 2020 at 11:59 PM (Central). Assessor is requested to send electronically in PDF or Word format to michael.sands3@va.gov.

Assessor: Please do not send this information to the Quoter being evaluated.

Thank you in advance for your cooperation and expeditious response to this request.

PAST PERFORMANCE QUESTIONNAIRE

SECTION A: Quoter Information (to be completed by the quoter for whose past performance information is being collected, prior to forwarding to assessors)

Solicitation Number 36A79720Q0007 Project/Requirement High Tech Medical Equipment (HTME) Inspection Services Customer/Agency U.S. Department of the Veterans Affairs, National Acquisition Center

(NAC), National Contracts Service (NCS), High-Tech Medical Equipment (HTME) Ordering Division

1. Prospective Government Contractor’s (Quoter) Name and Address: ______________________________________

2. Contractor Point of Contact: ___________________________________________

3. Phone number (with area code): ___________________________________________

4. Assessor Contract Award number: _________________________________________

5. Description of Services provided under contract:

6. Contract award date: ___________ Contract Amount: Initial ___________Final ____

7. Period of Performance:

ASSESSOR INFORMATION:

Assessor Name Title Phone Number/Email Address

8. Authorization is hereby granted to provide the information requested in this questionnaire to the U.S. Department of Veterans Affairs’ National Acquisition Center.

(Signature)

(Name and Title of Authorizing Official) (Date)

SECTION B: Assessor’s Information (to be completed by assessors.)

RATING SCALE Definitions

Exceptional (E) The Quoter exceeded the majority of our expectations or requirements and met all other expectations or requirements.

Good (G) The Quoter exceeded some of our expectations or requirements and met all other expectations or requirements.

Satisfactory (S) The Quoter met all of our expectations or requirements.

Marginal (M) The Quoter failed to meet some of our expectations or requirements.

Unsatisfactory (U) The Quoter failed to meet most of our expectations or requirements.

Neutral / Not Applicable or Unknown (N)

No performance record identifiable within the area of evaluation.

The questions in the survey (see below) shall be rated in accordance with the definitions provided in the Rating Scale above. Please supplement any ratings other than “Satisfactory” with an explanation in the space provided.

1. QUALITY:

Overall quality of services provided E G S M U N

Ability to meet quality standards specified for technical performance

E G S M U N

Timeliness/effectiveness of contract problem resolution without extensive customer guidance

E G S M U N

Adequacy/effectiveness of quality control plan and adherence to contract quality assurance requirements (without adverse effect on performance)

E G S M U N

2. SCHEDULE/TIMELINESS OF PERFORMANCE:

Compliance with contract delivery/completion schedules including any significant intermediate milestones

E G S M U N

Rate the contractor’s use of available resources to accomplish tasks identified in the contract

E G S M U N

3. CUSTOMER SATISFACTION:

Contractor was reasonable and cooperative in dealing with your staff (including the ability to successfully resolve disagreements/disputes; responsiveness to administrative reports, businesslike and communication)

E G S M U N

Professionalism of contractor E G S M U N

Overall customer satisfaction E G S M U N

4. MANAGEMENT/ PERSONNEL/LABOR

Management effectiveness (i.e. management of staff) E G S M U N

Ability to hire, apply, and retain a qualified workforce to this effort

E G S M U N

Knowledge/expertise demonstrated by contractor personnel E G S M U N

Ability to simultaneously manage multiple service locations E G S M U N

Ability to assimilate and incorporate changes in requirements and/or priority, including planning, execution and response to changes

E G S M U N

5. COST/FINANCIAL MANAGEMENT

Ability to meet the terms and conditions within the contractually agreed price(s)

E G S M U N

Have there been any indications that the contractor has had any financial problems? If yes, please explain below.

Yes

No

6. SAFETY/SECURITY

Contractor’s ability to maintain an environment of safety, adhere to its approved safety plan, and respond to safety issues

E G S M U N

Contractor compliance with all security requirements. E G S M U N

7. GENERAL

Compliance with contractual terms/provisions (explain if specific issues)

E G S M U N

Would you hire or work with this firm again? (If no, please explain below)

Yes No

In summary, provide an overall rating for the work performed by this contractor.

E G S M U N

Please provide straightforward responses to the questions above (if applicable) and/or additional remarks. Furthermore, please provide a brief narrative addressing specific strengths, weaknesses, deficiencies, or other comments which may assist our office in evaluating performance risk (attach additional pages if necessary):

ASSESSOR:

Identify your role in the contract award or administration and the period of your involvement.

Role Period of Involvement

Contract Specialist/Contracting Officer

Technical Project Lead/Project Officer

OTHERS

(Signature) (Date)

(Typed or Printed Name) (Organization Name)

(Phone Number) (Email Address)