36C24418R0671-003.docx

Past Performance Questionnaire The Department of Veterans Affairs is evaluating a proposal submitted by _________________________ [Offeror’s name], hereafter referred to as “Offeror,” to provide Emergency Room Physicians for the Wilkes Barre VAMC. Offeror has provided this questionnaire to you so that we may ask you questions regarding Offeror’s past performance on a similar contract between your company and Offeror.

Any information you provide in this questionnaire is considered Source Selection Information and is prohibited from disclosure and exempt from release under the Freedom of Information Act; as such, the Department of Veterans affairs will not release the your name or the names of other individuals providing reference information about Offeror’s past performance.

Instructions: Be honest. Provide an assessment of Offeror’s past performance by checking the box of one the following rating options. You are encouraged to write comments as often as you’d like.

Rating Options:

Satisfactory—Offeror’s performance meets (or met) all contractual requirements and performance was accomplished with minor issues or concerns, for which Offeror’s corrective actions were effective.

Unsatisfactory—Offeror’s performance does not meet (or did not meet) contractual requirements and performance was accomplished with significant problems, issues or concerns, for which Offeror’s corrective actions were ineffective.

Not Applicable—Unable to provide a meaningful assessment.

When you are finished, please email your completed questionnaire to: Maureen.Jordan @ Maureen.Jordan@va.gov .

THANK YOU FOR YOUR SUPPORT AND PARTICIPATION!

Performance Assessment

1. Reference Information Company Name: _______________________________________________________________________ Your Name: ___________________________________________________________________________ Contract Number (if Government): ________________________________________________________ Period of Performance: Start Date:_______________________ End Date:________________________ Scope of Services (e.g., contract dollar value, geographic coverage area, frequency of services, etc.):

2. Quality of performance Assess Offeror’s quality of performance in these areas:

Conformance to contract specifications (qualifications of personnel are met; have appropriate personnel to perform positions; capability to deliver timely services, etc.)

Standards of care (technical, professional, safety, and the like)

Timely deliveries of Temporary Personnel

3. Management performance Assess Offeror’s contract management performance in these areas:

Management responsiveness (timeliness, reliability, cooperation, etc.)

Management of personnel (hiring, training, retaining, replacing, etc.)

Management of program (coordination, use of resources, communication, risk management, etc.)

Management of conflicts or issues (reactive, provides good solutions, flexible to changing needs, etc.)

4. General comments

Assessor’s Signature:_____________________________________ Date:_____________________

THANK YOU FOR YOUR SUPPORT AND PARTICIPATION!

Source Selection Information—See FAR 2.101 and 3.104