Attachment Six (6) - Past Performance Questionaire.pdf

Attachment. D.6

RFQ 36C24822Q0181

PAST PERFORMANCE QUESTIONNAIRE

Request for Quote - 36C24822Q0181

3T Mobile Magnetic Resonance Imaging (MRI) services, along with a Board-Certified MRI Technologist(s), and a Tech. Assistant

1. Background: The Miami Veterans Affairs Healthcare System (MVAHCS) has an ongoing requirement for 3T Mobile Magnetic Resonance Imaging (MRI) services, along with a Board-Certified MRI Technologist(s), and a Tech. Assistant. The vendor has identified you as a reference to validate the their past performance. This question is concerns pass or current contractors/agreements for which you have personal knowledge.

2. Instruction: Please complete this questionnaire based on the following guidance. Please take the time to answer the questions to the best of your knowledge. Circle the responses that best describe the company’s performance and write in a narrative explanation for you answer. Use a N/A rating to indicate that you have no performance information for that particular area, or if the question does not apply to you. Each question has space for your comments. If more space is needed, please attach additional sheets to the end of the questionnaire and reference to respective questions. Handwritten (ink) responses are sufficient.

Please complete the following questionnaire to assist our evaluation of the company's past performance and return no later than the date the contractor advises. Please return to Rosetta Quinn email at Rosetta.quinn@va.gov.

Name of Company: _____________________________________________

Title/Description of Proposed Project:

Please evaluate the past performance using only the following ratings without variation. If the ratings is Marginal or Unsatisfactory, 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 meet the minimum contract requirements but some material aspects of the company's performance were less than satisfactory “U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements mailto:osetta.quinn@va.gov

CUSTOMER SATISFACTION

1. Company maintain a professional staff.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

2. Company was responsive to inquiries regarding contract/agreement.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

3. Company was flexible in responding two urgent requirements.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

4. Overall customer satisfaction.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

COMPLIANCE WITH STAFFING REQUIREMENTS

5. Company provided sufficient notice of personnel changes/additions, to ensure adequate time to credential personnel.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

6. Company consistently provided trained/qualified staff.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

7. Company ensured staff remained fully qualified/proficient at all times.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

8. What's the company ever issues a cure or show cause notice under the reference contract/agreement?

If yes, explain in “comments.” Yes/No

Comments:

9. Would you hire this company again?

If yes, explain in “comments.” Yes/No

Comments:

Overall Rating: ____________________________________

Name of Evaluator: ______________________________ E-Mail: ______________________________

Position Title/Grade: _____________________________ Phone Number: _______________________

Company/City: _____________________ Date Questionnaire Completed: ______________________