36C10G19R0018-007.docx

ATTACHMENT F: PAST PERFORMANCE QUESTIONNARE

Department of Veterans Affairs: 36C10G-19-R-0018 FSC Medical Health Claims Processing

PART 1:

TO: Insert Name, Contracting Officer AGENCY: Insert Agency/Company Name

PHONE: Insert Phone E-MAIL: Insert E-mail

INFORMATION REQUEST: PAST PERFORMANCE

The Department of Veterans Affairs is currently in the process of awarding a competitive service contract.

[CONTRACTOR NAME] has provided this Questionnaire to you for a reference regarding [CONTRACTOR NAME]’s record of past performance under Contract No. [CONTRACT #].

Send completed questionnaires to glenn.burtonjr@va.gov and Sharon.redman@va.gov

NOTE TO VENDORS: If the Questionnaire is provided for Subcontractors reference, the Vendor’s name below must include both the Prime and Subcontractor Names.

PART 2:

PAST PERFORMANCE QUESTIONNAIRE

Vendor’s Name:

Request for Quote: On-site Health Services Medical Claims Processing for the Department of Veterans Affairs, Financial Services Center (VA-FSC) Requirement

Name of Person Completing the Evaluation:

Telephone: E-mail:

Title:

Company/Organization:

Please rate the vendor in each of the following areas. Note: there is room for comments where you deem remarks would be helpful to our evaluation.

· Not Applicable: N/A

· Marginal (M) Performance occasionally does not meet minimum contract performance standard or requirement

· Acceptable (A) Performance that meets the minimum contract performance standard or requirement

· Good (G) Performance that meets and occasionally exceeds the contract performance standard or requirement

· Outstanding (O) Performance that almost always exceeds the contract performance standard or requirement

Overall satisfaction with the Vendor’s performance.

Delivery performance includes delivery consistency, on time performance, and flexibility in responding to emerging issues and implementing required solutions.

Rate the effectiveness and applicability of the plans and strategies delivered and the actual implementation of those.

This includes the vendor’s ability to solve problems, the speed in which they handle problems, and their effective delivery of resolutions.

Rate the quality of the contractor’s staff in executing the project work scope.

6. Have you issued a cure notice, show cause notice, suspension of progress payments or other letters directing the correction of a performance problem in the past 3 years?

|_| Yes |_| No If Yes, please explain.

7. Have you terminated this contractor for default within the past 3 years, or are there any pending termination actions? |_| Yes |_| No If Yes, please explain.

8. Based on the vendor’s overall performance, would you award them another contract?

|_| Yes |_| No If No, please explain.

9. Have you discussed any adverse past performance problems with the Vendor and given them an opportunity to comment? |_| Yes |_| No Please explain.

10. Do you file past performance information in a database that the Contracting Officer may search?|_| Yes |_| No Please explain.

11. If the contract had options, were those options exercised? |_| Yes |_| No Please explain.

12. What was the contract period of performance (i.e., when were services provided)?

13. What was the dollar value of the contract performed by the vendor?

14. Provide a brief description of the services provided by the vendor for this contract.

Please attach any past performance database reports or other material you deem appropriate for a full understanding of the Vendor’s past performance by the evaluator. Please provide information on any adverse performance by the contractor and the corrective actions taken.

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