D.7 Attachment_Past Performance Questionnaire.docx
DOCX document 24 KB Posted
- Attached to
- V225--ALS/BLS Ambulance and Wheelchair Van Transports for New Castle & Area Counties in DE, PA, and NJ
- Solicitation number
- 36C24426Q0463
About this file
This is a Past Performance Questionnaire template used by the Department of Veterans Affairs to evaluate contractor performance for wheelchair van services supporting the Altoona VA facility. The questionnaire is completed by past customers or evaluators of vendors being considered for award of VA contracts and must be returned to the Contracting Officer, Cynthia Laemmerhirt, at cynthia.laemmerhirt@va.gov prior to the RFQ deadline. The form requires evaluators to provide verified contact information and document their relationship with the contractor through reference and contract information fields, including company name, customer/agency name, product/service description, contract number, contract dollar value, and period of performance.
The questionnaire contains fourteen detailed performance assessment questions covering compliance with contract requirements, timeliness of performance, labor and safety standards adherence, contract management effectiveness, ability to meet peak demand periods, communication systems and dispatch capability, management of scheduled and unscheduled veteran patient transports, complaint and accident handling, staff integrity issues, willingness to correct noncompliance, administrative reporting timeliness, personnel management practices, overall work quality, and willingness to award future contracts. Evaluators must also provide general comments on contract compliance, any unacceptable performance, and additional remarks. The form is designed to be completed separately for each contract being evaluated and includes space for the evaluator's name, organization, contact information, and signature, with a note that the Contracting Officer reserves the right to contact evaluators to corroborate responses.
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Text version
PAST PERFORMANCE QUESTIONNAIRE
REFERENCE INSTRUCTIONS: The Department of Veterans Affairs is considering the Offeror detailed below for an award of a VA contract related to Wheelchair Van services for Altoona. Your comments would be appreciated regarding this firm’s past performance. Your comments are considered Source Selection Sensitive in accordance with IAW FAR 2.101 and FAR 3.104. We please ask that the Survey be completed by the evaluator and returned directly to the Contracting Officer at the following email address prior to the established Request for Quotation (RFQ) Deadline: cynthia.laemmerhirt@va.gov Special Note: The vendor being evaluated should complete the information detailed below to include the RFQ Deadline based upon the information contained in the respective Solicitation.
Solicitation/RFP No.: [Insert] Requiring Activity: [Insert] Contracting Officer Email: [Insert] Return By (Date/Time): [Insert] A. Reference & Contract Information (to be completed by Past Performance Predecessor Company/Evaluator)
· Company/Division name:
· Customer/Agency/Facility name and Phone Number:
· Product/Service:
· Contract Number:
· Contract Dollar Value:
· Period of Performance (From/To):
· Verified, up-to-date name, title, email address, and telephone number of a reliable point of contact.
· Comments regarding compliance with contract terms and conditions
· Comments regarding any known performance deemed unacceptable to the customer, or not in accordance with the contract terms and conditions.
Special Note: Please Use an individual form for each respective contract being evaluated.
Performance Confidence Assessments Rating Method Table 2.
Questions below shall be completed.
Q1. Describe how the contractor complies with contract requirements?
Q2. Describe how timely was the contractor’s performance?
Q3. Describe how well does / did the contractor comply with labor and safety standards?
Q4. Describe the effectiveness of the contractor’s management of the contract.
Q5. Describe the contractor’s ability to meet various peak time periods to ensure requests for service response time meets PWS requirements.
Q6. Describe the contractor’s communication system (i.e., VetRide, cell phone, computer, etc.), dispatch, capability of real time communication for patient tracking purposes, and with the station POC.
Q7. Describe the contractor’s ability to manage scheduled and unscheduled Veteran patient pick-ups and transports as well as unscheduled evening and weekend long distance trips.
Q8. Describe the contractor’s handling of complaints, accidents, and reporting process.
Q9. Describe the contractor’s handling of staff integrity issues.
Q10. Describe the contractor’s willingness to improve and correct noncompliance issues and concerns.
Q11. Describe the contractor’s timeliness in providing any administrative reports/ documents required by your contract.
Q12. Describe the contractor’s personnel management practices.
Q13. Quality control: Describe the overall quality on the contractor’s work.
Q14. Would you award another contract to the contractor being evaluated? If yes or no, please explain:
Additional Remarks:
Name of Evaluator:
Evaluator’s Company/Organization:
Phone Number:
Email:
Evaluator’s Signature:
The CO reserves the right to contact the evaluator to corroborate the PPQ.
File details come from the government source that posted it. Updated .