36C24819R0150-006.pdf

RFP 36C24819R0150

PAST PERFORMANCE QUESTIONNAIRE

1.0 Please complete this questionnaire in regards to the identified firm providing Advanced and

Basic Life Support Transportation Services (ALS/BLS Ambulance). Handwritten responses are sufficient. If you need more space than that provided, please attach additional pages. Responses will be treated as source selection sensitive information. Return the completed questionnaire no later than the closing date located in section Instructions to Quoters, beginning on page 84 of the Solicitation, to:

Name:

Office:

Address:

Telephone:

Email:

LaVerne Astroth

NCO 8

8875 Hidden River Parkway Suite 525 Room 512 Tampa, Florida 33647

813-631-2815

LaVerne.Astroth@va.gov

2.0 Please complete the following identifying information and past performance assessment:

(a) Was the Contractor a prime contractor or subcontractor? (please circle one- subcontractor or prime)

(b) Name of Company providing evaluation:

(c) Identify Contract evaluating:

(d) Dates/Period of Performance:

(e) Negotiated price or cost at award:

(f) Current estimated contract dollar amount:

(g) Describe scope of contract and contract type:

3.0 Explanation of codes:

CODE PERFORMANCE LEVEL

E EXCEPTIONAL - Performance exceed contractual requirements. The contractual performance of the element or sub-element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were highly effective.

(Note: If rated “Exceptional”, please provide a brief statement of why they exceed many requirements)

S SATISFACTORY - Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor were satisfactory.

M MARGINAL - Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented. (Note: If rated

“Marginal”, please provide a brief statement of why they do not meet some requirements)

U UNSATISFACTORY - Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

(Note: If rated “Unsatisfactory”, please provide a brief statement of why they do not meet some requirements)

4.0 Circle the appropriate letter for each item on the questionnaire and provide supporting narrative.

ASSESSMENT ELEMENTS

(1) Please rate the contractor’s safety. Were there any instances in which complaints were received with regard to patient safety? Did any accidents occur during the performance period?

If yes, please provide a brief description.

E S M U

(2) Please rate the contractor’s timeliness. Were then any instances where patient treatment was rescheduled due to a failure to pick up as scheduled? If yes, please provide the number of occurrences and a short description of the incident.

E S M U

(3) Please rate the contractor’s response to issues. Did the Contractor remedy issues in an effective and timely manner?

E S M U

(4) Please rate the contractor’s ability to provide services. At anytime were services obtained from an alternate source due to contractor availability.

E S M U

(5) What is your overall rating of the contractor’s performance?

E S M U

(6) Identify the contractor's overall strengths and weaknesses.

(7) Given the choice, would you award to this contractor again? Please expand on your answer below.

(If more comment space needed, write on and attach additional pages.)

5.0 Please provide the name, title, address, and phone number of the person completing this questionnaire.

Phone FAX_____ _ _____________

6.0 Thank you for your assistance in this source selection. If you have any questions, please contact me, see contact info top of page.