Attachment D2 - Experience Questionnaire.pdf
PDF 174 KB Posted
- Attached to
- AMBULANCE ALS/BLS SERVICES
- Solicitation number
- 36C24826R0015
About this file
This document contains three identical Experience Questionnaires (#1, #2, and #3) to be completed by contractors or references regarding firms providing Advanced and Basic Life Support Transportation Services (ALS/BLS Ambulance). All three questionnaires must be returned no later than June 5, 2026, to J'Vonne Wilson at the VA's NCO 8 office located at 8875 Hidden River Parkway, Suite 160A, Tampa, FL 33647, by phone at (813) 816-4620, or by email at jvonne.wilson@va.gov.
Each questionnaire requests identifying information about an evaluated contract, including whether the contractor served as prime or subcontractor, the principal agency/company, the representative's name and title, contract identification, period of performance, negotiated price at award, and current estimated contract dollar amount. The assessment section requires detailed narratives addressing six key evaluation areas: (1) description of ambulance services performed, including whether services involved emergency response, non-emergency transport, interfacility transport, standby coverage, dispatch support, or other related services; (2) scale of effort including approximate number of ambulances, staffing levels, service area, and monthly call/transport volume for BLS, ALS, and Critical Care Transport (CCT); (3) operating environment and hours of support, such as hospital, military installation, federal campus, municipality, or urban/rural environment, with identification of operating hours (24/7, daytime, etc.); (4) overall satisfaction with contractor performance and explanation of any concerns; (5) any significant issues encountered during performance relevant to assessing contractor experience; and (6) likelihood of future award based on overall experience. Responses will be treated as source selection sensitive information. Handwritten responses are acceptable, and respondents may attach additional pages if needed.
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EXPERIENCE QUESTIONNAIRE #1
1.0 Please complete this questionnaire regarding 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 June 5, 2026 to:
Name: J'Vonne Wilson Office: NCO 8 Address: 8875 Hidden River Parkway, Suite 160A
Tampa, FL 33647 Telephone: (813) 816-4620 Email: jvonne.wilson@va.gov
2.0 Please complete the following identifying information and Experience assessment:
(a) Was Contractor prime contractor or subcontractor? _________________________________
(b) Principal Agency/Company: __________________________________________________
(c) Agency/Company Representative Name/Title: ____________________________________
(d) Identify Evaluated Contract: ___________________________________________________
(e) Dates/Period of Performance: __________________________________________________
(f) Negotiated price or cost at award: _______________________________________________
(g) Current estimated contract dollar amount: _________________________________________
(h) Describe overall scope of contract and contract type: ______________________________
3.0 Answer all questions and provide a supporting narrative.
ASSESSMENT QUESTIONS
(1) Please describe the ambulance services the contractor performed under this effort.
Include whether the services involved emergency response, non-emergency transport, interfacility transport, standby coverage, dispatch support, or other related ambulance services.
(2) What was the scale of this effort? Please describe the approximate number of ambulances, staffing levels, service area, and call/transport volume per month for Basic Life Support (BLS), Advanced Life Support (ALS), and/or Critical Care Transport (CCT), if known.
(3) What type of operating environment and hours did the contractor support under this effort? For example, hospital or medical treatment facility, military installation, federal campus, municipality, urban/rural environment, or other comparable setting. Also, identify operating hours for this effort (i.e. 24/7, 6:00am – 6:00pm).
(4) Did the contractor perform the effort in a satisfactory manner overall? If no, please briefly explain the concerns.
(5) Were there any significant issues encountered during performance that are relevant to assessing the contractor’s experience performing similar ambulance services?
(6) Given the choice, would you award to this contractor again based on their overall experience providing Ambulance Services? Please expand on your answer below.
EXPERIENCE QUESTIONNAIRE #2
1.0 Please complete this questionnaire regarding 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
Address: 8875 Hidden River Parkway, Suite 160A
Tampa, FL 33647
(b) Principal Agency/Company: __________________________________________________
(c) Agency/Company Representative Name/Title: ____________________________________
(d) Identify Evaluated Contract: ___________________________________________________
(e) Dates/Period of Performance: __________________________________________________
(f) Negotiated price or cost at award: _______________________________________________
(g) Current estimated contract dollar amount: _________________________________________
(h) Describe overall scope of contract and contract type: ______________________________
Include whether the services involved emergency response, non-emergency transport, interfacility transport, standby coverage, dispatch support, or other related ambulance services.
(2) What was the scale of this effort? Please describe the approximate number of ambulances, staffing levels, service area, and call/transport volume for Basic Life Support (BLS), Advanced Life Support (ALS), and/or Critical Care Transport (CCT), if known.
example, hospital or medical treatment facility, military installation, federal campus, municipality, urban/rural environment, or other comparable setting. Also, identify operating hours for this effort (i.e. 24/7, 6:00am – 6:00pm).
(4) Did the contractor perform the effort in a satisfactory manner overall? If no, please briefly explain the
(5) Were there any significant issues encountered during performance that are relevant to assessing the
(6) Given the choice, would you award to this contractor again based on their overall experience providing
EXPERIENCE QUESTIONNAIRE #3
1.0 Please complete this questionnaire regarding 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
Address: 8875 Hidden River Parkway, Suite 160A
Tampa, FL 33647
(b) Principal Agency/Company: __________________________________________________
(c) Agency/Company Representative Name/Title: ____________________________________
(d) Identify Evaluated Contract: ___________________________________________________
(e) Dates/Period of Performance: __________________________________________________
(f) Negotiated price or cost at award: _______________________________________________
(g) Current estimated contract dollar amount: _________________________________________
(h) Describe overall scope of contract and contract type: ______________________________
Include whether the services involved emergency response, non-emergency transport, interfacility transport, standby coverage, dispatch support, or other related ambulance services.
(2) What was the scale of this effort? Please describe the approximate number of ambulances, staffing levels, service area, and call/transport volume for Basic Life Support (BLS), Advanced Life Support (ALS), and/or Critical Care Transport (CCT), if known.
example, hospital or medical treatment facility, military installation, federal campus, municipality, urban/rural environment, or other comparable setting. Also, identify operating hours for this effort (i.e. 24/7, 6:00am – 6:00pm).
(4) Did the contractor perform the effort in a satisfactory manner overall? If no, please briefly explain the
(5) Were there any significant issues encountered during performance that are relevant to assessing the
(6) Given the choice, would you award to this contractor again based on their overall experience providing
| EXPERIENCE QUESTIONNAIRE #1 |
| EXPERIENCE QUESTIONNAIRE #2 |
| EXPERIENCE QUESTIONNAIRE #3 |
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