36C24919Q0184-020.docx

D.5. Past Performance Questionnaire 36C24919Q0184

REFERENCE INSTRUCTIONS: The Network Contracting Office 9 is soliciting for award of a VA contract for On-Site Gastroenterology Physician Services to eligible beneficiaries. Your comments would be appreciated regarding this firm’s past performance. The intent of this form is to evaluate contractors who have provided Gastroenterology Physician Services in the past.

Survey must be completed by evaluator and sent to Lori L Ellis via email at Lori.Ellis2@va.gov

Information of Company to be Evaluated Company name:

Address:

Phone:

Email:

Information of Evaluating Agency

Information regarding your Contract with the company to be evaluated:

Estimated Contract Amount: $ Contract Period of Performance:

Type of Services rendered:

Please evaluate the past performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, 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 contractor’s performance were less than satisfactory

“U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements

Q1. To what extent did the contractor comply with contract requirements?

O A S M U

Q2. If reports were required, were they accurate in meeting contract requirements?

O A S M U

Q3. To what extent did the contractor use appropriate personnel for contract requirements?

O A S M U

Q4. To what extent was contractor able to meet the performance schedule:

O A S M U

Q5. What extent was contractor flexible in responding to changing needs?

O A S M U

Q6. To what extent was the contractor reliable?

O A S M U

Q7. To what extent was the contractor responsive to technical directions?

O A S M U

Q8. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, please explain.

Yes No

Q9. Would you award another contract to the party being evaluated? If no, please explain:

Yes No

Q10. To what extent did contractor notify you of problems or potential problems?

O A S M U

11. Please describe services provided under your contract, period of performance and total cost:

12. Additional Remarks:

Signature of Evaluator

Date