36C24418Q9343-005.docx

SAMPLE COR CONTRACTOR PERFORMANCE EVALUATION REPORT

COR NAME: LOCATION:

SERVICES PROVIDED:

CONTRACTOR:

CONTRACT NO:

PURCHASE ORDER NO:

PERIOD OF PERFORMANCE: (MM/DD/YYYY-MM/DD/YYYY)

COST / PER UNITS DELIVERED OF SERVICES DURING REPORTING PERIOD:

Review of Contractor Payments, obligations and remaining balances on purchase orders to ensure obligation of money keeps pace with actual usage. Information can be obtained from https://vaww.ipps.fsc.va.gov/prweb/PRWebLDAP1. PLEASE ENSURE INVOICES FROM WEB SITE WITH DATES OF SERVICES ARE UPLOADED TO THE ECMS BRIEFCASE

TOTAL $ ___________ invoices for period (See invoices in contract file) TOTAL $ ___________ not invoiced for services received

COMPLETE INVOICE AUDIT SUMMARY

1. WAS THE CUSTOMER SERVICE/PATIENT SATISFACTION IN ACCORDANCE WITH SCOPE OF WORK?

[ ] Yes [ ] No - Describe any deficiencies:

Has the contractor met the expectations for access and timeliness of services to meet patient care needs? (e.g. turnaround time for routine vs. emergent services; turnaround time for reports of patient care services, etc.)

[ ] YES [ ] NO Comments: __________________________________

Have there been any patient safety reports from the contractor that have documented injury or harm to our patients?

[ ] YES [ ] NO Comments: __________________________________

Have any VA patients filed any malpractice claims against the contractor?

[ ] YES [ ] NO Comments: __________________________________

Have any patients filed complaints regarding dissatisfaction with care provided by the contractor?

[ ] YES [ ] NO Comments: __________________________________

2. WERE THE CONTRACTOR'S SERVICES/PRODUCTS IN ACCORDANCE WITH SCOPE OF WORK?

[ ] Yes [ ] No - Describe any deficiencies:

Have there been any concerns related to the quality of services being provided by the contractor?

[ ] YES [ ] NO Comments: __________________________________

Has the contractor complied with documentation requirements as defined in the contract?

[ ] YES [ ] NO Comments: __________________________________

3. CONTRACTOR FOLLOWED CONTRACT SCHEDULE REPORTING (I.E. TIMELY AND CORRECT INVOICING MATCHING COR RECORDKEEPING, DELIVERY SCHEDULE, PROGRESS SCHEDULE, PERFORMANCE SCHEDULE, ETC.)

[ ] Yes [ ] No - Describe any deficiencies:

4. HAVE YOU, AS COR, PROVIDED TECHNICAL ASSISTANCE TO THE CONTRACTOR?

[ ] Yes [ ] No - Describe why not:

5. STATE ANY OTHER SIGNIFICANT ISSUES WHICH SHOULD BE BROUGHT TO THE CONTRACTING OFFICER'S ATTENTION.

6. REVIEW OF CONTRACTOR / SUB-CONTRACTOR TRAINING (ATTACHMENT B).

COR Comments

Were comments, correspondence, or any additional information provided to the contracting office during this rating period? Yes No

By signing below, you are certifying that: you have copies of all contract documents required to fulfill your duties, have been briefed and understand the authority (and limits of authority) given you, have received responses to any question or concern given to the contracting officer, have notified the contracting officer of any information that impacts the performance of this contract and understand any pending requirements and related due dates for procurement information in the upcoming quarter:

Name and title of rating COR: _____________________________________

COR Signature Date:

CO Comments:

CO Signature Date:

VHAPM Part801.603-70 COR SOP Revision 04 Page 1 of 2 Original Date: 05/20/2011 Revision 04 Date: 06/30/2017