36C24723R0011 WHEELCHAIR Past Performance Survey.pdf

REFERENCE INSTRUCTIONS: Charlie Norwood VA Medical Center, Augusta GA is considering the offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. The intent of this form is to evaluate Wheelchair / Van Services. Your comments are considered Source Selection Sensitive;

therefore, you are advised that the Federal Acquisition Regulation (at FAR 15.506(e) prohibits the release of the names of individuals providing reference information about Offeror’s past performance.

Name of Offeror being evaluated:

Address of Offeror:

Contract Details (i.e. Contract Number / Delivery or Task Order Number, Title, Location, etc.):

Name of Evaluator:

Position held or function in relation to project:

Company Name:

Address:

Contact Phone Number:

Facsimile Number:

Please complete and return to darius.crane@va.gov no later than 12/30/2022 12:00 AM ET

Please evaluate the past performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, please provide additional information in the appropriate block or in the remarks section of this form.

“O” = Outstanding = Performance greatly exceeded the contract requirements “A” = Above Average = Performance exceeded the contract requirements

“S” = Satisfactory = Performance met the contract requirements “M” = Marginal = Performance met the minimum contract requirements but some material aspects of the Contractor’s performance were less than satisfactory “U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements

Please rate and provide information/comments for the following:

Circle one

Q1. To what extent did the Contractor comply with contract requirements?

O

O A S M U

Q2. If reports were required, were they accurate in meeting contract requirements?

Q3. To what extent did the Contractor use appropriate personnel for contract requirements?

Q4. To what extent did the Contractor display technical expertise?

Q5. Quality control: