36C24518Q0219-004.pdf

Source Selection Information—See FAR 2.101 and 3.104

Past Performance Questionnaire

The Department of Veterans Affairs is evaluating a proposal submitted by _________________________

[Offeror’s name], hereafter referred to as “Offeror,” to provide coding auditing services for the VHA

Compliance & Business Integrity Office. 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 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:

Excellent ‐ Offeror’s performance exceeded all contractual requirements and performance exceeded expectations with no or inconsequential issues.

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 James.Whisner@va.gov; or, fax it to 304‐623‐7637.

THANK YOU FOR YOUR SUPPORT AND PARTICIPATION!

Performance Assessment

1. Reference Information

Company Name: _______________________________________________________________________

Assessor’s 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. Performance Rating

a. Quality of performance

Assess Offeror’s quality of performance in these areas:

Excellent Satisfactory Unsatisfactory N/A

Conformance to contract specifications

Quality of workmanship (technical, professional, safety, and the like)

Timely deliveries

b. Management performance

Assess Offeror’s contract management performance in these areas:

Excellent Satisfactory Unsatisfactory N/A

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

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

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

3. Additional Information

a. Did the Offeror adhere to contract schedules? COMMENT:

b. Did the Offeror submit all required reports and documentation in a timely manner? Were the accurate and complete? COMMENT:

c. Did you experience any problems with the Offeror’s performance? Was the Offeror able to resolve the problems without extensive help from you staff? COMMENT:

d. How well did the Offeror interface with your staff? COMMENT:

e. What extent was Offeror flexible in responding to changing needs? COMMENT:

f. Based on your experience with this Offeror, would you consider using them again? How do they compare to other Offerors you have used? COMMENT:

g. Based on your experience what is your overall rating of the Offeror? COMMENT:

Excellent ( ) Satisfactory ( ) Unsatisfactory ( )

4. General comments

Assessor’s Signature: _____________________________________ Date: _____________________

THANK YOU FOR YOUR SUPPORT AND PARTICIPATION!