36C24820Q0531-004.docx

Past Performance Questionnaire Instructions

The “quoter” (identified in Section I, Block A) is submitting a response to a solicitation issued by the Department of Veterans Affairs, James A. Haley Veterans Hospital (JAHVH) and clinics, including: New Port Richey, Brooksville, Lakeland and Zephyrhills, Florida, to perform Employee Assistance Program services.

Your candid responses to this questionnaire will assist in evaluating the quoters past performance (i.e. How was the quality of the services this offeror provided in the past?). By gathering this information (not only on this quoter, but on all the companies who submit a quote to provide these required services) we strive to determine which company’s quote will be most advantageous to VA.

PLEASE EMAIL COMPLETED Questionnaires no later than 30 March 2020 @ 10:30 A.M. EST to: Keila President EMAIL: keila.president@va.gov

Should you have any questions regarding this questionnaire, please feel free to contact the above contract specialist at (813)978-5998 or email above.

Section I - Details of Company Being Evaluated

A. Offeror’s Information:

1. Company

2. Address:

3. Company POC’s Name:

4. POC’s Title:

5. POC’s Phone #:

6. POC’s Email:

B. Information regarding Past Contract(s*) being evaluated: *(attach additional pages if necessary)

1. Contract #:

2. Customer (Firm Name):

3. Location(s) of Work Performed:

4. Scope of Contract (i.e. Brief Description of Work Performed).:

5. Dates work was performed:

SECTION II - Details of Evaluator (Person providing Evaluation of Offeror)

1. Evaluator’s Name:

2. Title:

3. Organization:

4. Evaluator’s Phone #:

5. Evaluator’s Fax #:

6. Evaluator’s Email:

SECTION III - Customer Satisfaction/Quality of Service Questions (To be Filled Out only by the “Evaluator”)

PERFORMANCE LEVEL- Rating/definitions OUTSTANDING- Performance meets contractual requirements and exceeds many (requirements) to the Government’s benefit. The contractual performance of the element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

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

NEUTRAL- Past Performance was never obtained or completed to determine if it meets contractual requirements.

MARGINAL- Performance does not meet some contractual requirements. The contractual performance of the 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.

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

KEY: O=OUTSTANDING S=SATISFACTORY N=NEUTRAL M=MARGINAL F=FAIL

Section IV: Closing Comments

1. Provide any additional comments you feel would be pertinent regarding past performance of this company:

PLEASE EMAIL COMPLETED QUESTIONNAIRES to: keila.president@va.gov