36C24818R0308-004.pdf

PAST PERFORMANCE

QUESTIONNAIRE

Request for Proposal:

36C24818R0308

VA Medical Center

(VAMC)

Community Nursing Home Services

Message to the assessor: Your assistance is requested by Jonathan D. Locklear, the Contract Specialist to assist with establishing the performance history for the Company (Offeror) named below. In efforts to expedite receipt of the requested information, the Contracting Office respectfully requests that you do not mail hard copies. Instead, please e-mail the completed past performance questionnaire(s) to:

Jonathan.Locklear@va.gov. If not enough space is provided, please attach additional information to this questionnaire. Please return the past performance questionnaire on or before the closing date of the solicitation.

1. Name of Offeror /Agency: Contract or Identifying Number:

Title/Description of Contract:

Based upon the definitions below, indicate your assessment of the offeror’s performance. Your assessment should consider the offeror’s performance in accordance with the contractual requirements. Please include the period of performance and contract value:

2. Brief description of scope of work:

EVALUATION: Please rate the offeror using the guide below. Explanatory narratives for as many responses as possible would be appreciated. These narratives need not be lengthy, just detailed. Attach additional pages if more space is needed.

Assessment Definition

Outstanding (O) The Offeror’s performance met contractual requirements and exceeded many requirements to the Client’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the offeror were

Above Average (A) The Offeror’s performance met contractual requirements and exceeded some requirements to the Client’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the offeror were effective.

Satisfactory (S) The Offeror’s performance met contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the offeror were satisfactory.

Unacceptable (U) Performance did not meet contractual requirements. The contractual performance reflected a serious problem for which the offeror has yet to identify corrective actions or the offeror’s proposed actions appear only marginally effective or were not fully implemented.

Completed scheduled services in a timely manner per the Performance Work Statement (PWS).

O A S U

Compliance with contractual Terms and Conditions. O A S U Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period.

O A S U

Provided effective quality control and/or inspection procedures to meet contract requirements.

O A S U

Corrected deficiencies in timely manner and pursuant to the offeror’s quality control procedures.

O A S U

Exhibited knowledge of and compliance with Government (or other) regulations and industry standards.

O A S U

How effective was the offeror in responding to urgent requests in a timely manner per the Performance Work Statement (PWS)?

O A S U

To what extent was the offeror able to solve contract performance problems without extensive guidance from procurement or technical

O A S U

Provides timely and accurate documents, records, and invoices as required by the contract.

O A S U

Would you award similar contracts to this offeror? Please provide explanation for response.

YES NO

Rate the Offeror’s OVERALL quality of performance under this contract O A S U

EXPLANATION OF OVERALL RATING GIVEN:

ADDITIONAL COMMENTS (as required)

Name & Signature of Assessor’s:

Company/Agency: Date:

Position Title/Grade: Phone:

Email: Fax: