Attachment D Past Performance Questionnaire Med Gas for Miami.pdf

Attachment C 36C24822Q0322 Past Performance Questionnaire

PAST PERFORMANCE QUESTIONNAIRE

Request for Quote – 36C24822Q0322 Medical Gas/Cylinder Delivery

1. Background: The VA Network Contracting Office – 8, Miami, FL is conducting a competitive acquisition for Medical Gas and Cylinder Delivery for the Miami Healthcare System and its designated catchment area. The quoter has identified you as a reference to validate the quoter’s past performance. This questionnaire concerns past or current contracts/agreements for which you have personal knowledge.

2. Instructions: 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 short narrative explanation for your answer.

Use a N/A rating to indicate that you have no performance information for that area, or if the question does not apply to you. 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 11:59 PM (EST) on March 25, 2022 to Jose Delgado, email at jose.delgado3@va.gov.

Name of Company: U.S Department of Veteran Affairs – Network Contracting Office 8 Contracting Officer.

Title/Description:

Delivery of Medical Gas and Cylinders for the Miami VA Healthcare System.

Please evaluate the past performance using only the following ratings without variation. If the rating 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 met 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:scott.brickey@va.gov

Past Performance Questionnaire

CUSTOMER SATISFACTION

1. Contractor maintained appropriate and professional staffing levels to meet the requirement.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

2. Quality of service and workmanship.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

3. Timeliness/Adherence to Delivery schedules.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

4. Quality Control.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

5. Overall customer satisfaction.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

6. If past performance information is from a Government contract, was the contractor ever issued a cure or show cause notice or contract discrepancy report? If so, give details and contract/agreement number?

If yes, explain in “comments.” Yes /No

Past Performance Questionnaire

Comments: ________________________________________________________________________

7. If given the opportunity would you award to this contractor?

If no, explain in “comments.” Yes /No

BRIEF EXPLANATION OF RATING GIVEN:

Name of Evaluator: _________________E-Mail: _______________________

Signature:

Position Title /Grade: ___________________ Phone Number: ____________________

Company/City: ______________________________________

Date questionnaire completed: __________________________