36C24521Q0514 Attachment- Past Performance Questionnaire.docx

Past Performance Questionnaire RFQ No. 36C24521Q0514 The Department of Veterans Affairs is evaluating an offer from ___________________ [Offeror’s name], hereafter referred to as “Offeror,” to provide re-accreditation services for 40 VHA Radiation Oncology centers. 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. Past performance must be able to show:

· Three radiology accreditations for a facility of equal size within the last five years.

· The number of new facilities surveyed for accreditation per year.

· The number of facilities surveyed for the renewal of accreditation per year.

· The number of facilities surveyed for radiology accreditation to date.

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:

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.

Neutral - Unable to provide a meaningful assessment.

When you are finished, please email your completed questionnaire to Rachael.Hallock@va.gov.

THANK YOU FOR YOUR SUPPORT AND PARTICIPATION!

Performance Assessment

1. Reference Information Your Company’s Name: _________________________________________________________________ Your Name: __________________________________________________________________________ Contract Number (if Government): ________________________________________________________ Period of Performance: Start Date: _______________________ End Date: ________________________ Scope of Services (e.g., types of services provided, types of sterilization equipment serviced, contract dollar value, etc.):

2. Performance Rating

a. Quality of performance

Conformance to contract specifications

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

Timely submittal of all reports and documentation

b. Management performance

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. General comments

Assessor’s Signature: _____________________________________ Date: _____________________

Source Selection Information—See FAR 2.101 and 3.104