36C24918R0178-009.docx

ATTACHMENT 7: PAST PERFORMANCE SURVEY

SUBJECT: Past Performance Survey for Mobile Lithotripsy Services for the Louisville, KY VA Medical Center – RFP 36C24918R0178

FOR PROVIDERS OF PAST PERFORMANCE INFORMATION

NCO 9 Contracting, Murfreesboro, Tennessee, has issued a solicitation for provision of Mobile Lithotripsy Services for the Louisville VA Medical Center.

Past performance information will be used in the evaluation of proposals received. Section A of the enclosed survey lists the contractor who has identified your office as a source to evaluate their past performance. Section A also authorizes release of this information to NCO 9 Network Contracting Activity, Murfreesboro, Tennessee.

An individual knowledgeable of the contractor’s quality of supplies and services rendered should complete the survey, providing comments wherever applicable. Supplemental information from others in your organization is encouraged. If evaluating more than one contract for the same contractor, use a separate survey for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing it is greatly appreciated. The survey should be completed as soon as possible but not later than January 19, 2018. Send electronically to Pretial.caston@va.gov, or fax the survey to 615-849-3789.

Do not provide a copy of the completed survey to the contractor.

Thank you in advance for your cooperation and expeditious response to this request.

PAST PERFORMANCE SURVEY (Solicitation 36C24918R0178) SECTION A: Contractor Information (to be completed by the contractor for who past performance information is being collected, prior to forwarding to respondent)

1. Prospective Government Contractor’s ________________________________________

2. Contractor Point of Contact: ________________________________________________

3. Phone number (with area code):______________________________________________

4. Contract number: _______________________________

5. Description of Services provided under contract: ___________________________________________________________________________

6. Contract award date: ___________ Contract award amount: _________________

7. Period of Performance or Delivery Date: ________________________________________

8. Authorization is hereby granted to provide the information requested in this survey to NCO 9 Network Contracting Activity, Murfreesboro, Tennessee (Signature)

SECTION B: Respondent Information (to be completed by respondent)

Respondent should complete survey and submit No later than: January 19, 2018

RATING SCALE

The following Rating Scale provides the definitions for the Past Performance ratings to be assessed:

The questions on the survey (see below) shall be rated in accordance with the definitions provided in the Rating Scale. Any unsatisfactory or marginal rating shall be supplemented with an explanation in the space provided.

QUALITY OF SERVICE

COMMENTS:

SCHEDULE

1. Delivery of service was within required time period specified by contract requirements. E V S M U N

2. Rate the contractor’s ability to submit invoices.

Are they complete and accurate and timely? E V S M U N

COMMENTS:

BUSINESS RELATIONS

1. Overall rating of contractor’s business practices (e.g. maintaining A positive working relationship, business ethics, timely and effectively resolution of any problems, etc.) E V S M U N

2. Rate the working relationship between contractor’s management, and your company (i.e. contractor’s history of reasonable and cooperative behavior, commitment of customer satisfaction; concern for the interest of the customer). E V S M U N

3. Rate the contractor's ability to submit required reports and/or invoices in a timely manner. E V S M U N

4. Rate the contractors responsiveness to customer complaint resolution. E V S M U N

5. Overall rating of contractor’s business relations. E V S M U N

COMMENTS:

How would you feel about awarding another contract to this contractor?

______ Would not hesitate to award another contract to this contractor.

______ Would most likely award another contract to this contractor.

______ Would think twice about awarding another contract to this contractor, but would do so if no better alternative existed.

______ Do not wish to award another contract to this contractor.

______ Would not award another contract to this contractor.

COMMENTS:

ADDITIONAL REMARKS: