36C24818Q0683-008.pdf

D.6 PAST PERFORMANCE QUESTIONNAIRE

REFERENCE INSTRUCTIONS: The Bay Pines VA Healthcare System is considering the Quoter listed below 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 the Quoter’s experience. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation prohibits the release of the names of individuals providing reference information about Quoter’s past performance. This survey should be completed by an evaluator with sufficient familiarity of the Quoter’s performance and returned to the contracting office by the evaluator no later than July 9, 2018 at 1:00 PM EST by e-mail to Mark.Cline@va.gov.

Quoter’s Name: Quoter’s e-mail: __________________

Request for Quote: Home Oxygen (Bay Pines VAHCS)

Solicitation Number: 36C24818Q0683

Name of Person Completing the Evaluation:

Telephone: E-mail: ______

Title:

Company/Organization:

Please rate the Quoter in each of the following areas. Note: there is room for comments where you deem remarks would be helpful to our evaluation.

Not Applicable: N/A 1: Performance below the contract performance standard or requirement.

2: Performance that met or exceeded the contract performance standard or requirement.

1. Rate your overall satisfaction with the Quoter’s performance. 1 2 N/A

2. Did the Quoter demonstrate their ability to control costs and meet mandatory delivery schedules?

1 2 N/A

3. Satisfaction with the quality of equipment delivered. Consider effectiveness and applicability of the plans and strategies delivered and the actual implementation of those.

4. Satisfaction with problem resolution. This includes the Quoter’s ability to identify potential road blocks, identify courses of action, solve problems, the speed in which they handle problems, and their effective delivery of resolutions.

5. Satisfaction with the quality of Quoter personnel. Rate the quality of the Quoter’s staff in executing the project work scope.

6. Have you issued a cure notice, show cause notice, suspension of progress payments or other letters directing the correction of a performance problem? Yes No If Yes, please explain.

7. Have you terminated this Quoter for default or are there any pending termination actions?

Yes No If Yes, please explain.

8. Based on the Quoter’s overall performance, would you award them another contract?

Yes No If No, please explain.

9. Have you discussed any adverse past performance problems with the Quoter and given them an opportunity to comment? Yes No Please explain.

10. Do you file past performance information in a database that the Contracting Officer may search?

Yes No Please explain.

11. If the contract had options, were those options exercised?

Yes No Please explain.

12. List the dates of the contract period of performance (when was the supplies/services provided)?

13. Dollar value of the contract performed by the Quoter? ____________________

14. Select the equipment used on the contract:

Ventilators Gas O2 Liquid O2

15. Provide a brief description of the supplies/services provided by the Quoter for this contract. You may also include information you deem important to the Quoter’s performance during the contracted period.

Please attach any past performance database reports or other material you deem appropriate to a full understanding of the Quoter’s past performance by the evaluator.