36C24919R0181-004.docx
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- 36C24919R0181
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36C24919R0181 S02-Attachment 4-Ultrasound Past Performance Survey.docx
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36C24919R0181 - ATTACHMENT 4 PAST PERFORMANCE SURVEY
ULTRASOUND, MRI AND CT TECHNICIAN SERVICES
REFERENCE INSTRUCTIONS: The Department of Veterans Affairs is seeking offerors for award of a VA contract for a total of five (5) Ultrasound, MRI and CT Technician (two ultrasound technologist/two MR technologists, and one CT Tech) Services for a base year plus one option year. You have been identified as a reference and your comments would be appreciated. Your comments are considered Source Selection Sensitive; therefore, you are advised that the release of the names of individuals providing reference information about Offeror’s past performance is prohibited. Survey should be completed by evaluator and submitted no later than August 12, 2019 @ 3:00 p.m. CT via email directly to cheri.burton-crutcher@va.gov.
NOTE: Incomplete or unsigned surveys will not be considered.
Company being evaluated:_______________________________________________ Period of Performance:__ What was the average monthly volume of the services provided? (Number of cases per month? Average number of hours per case?) __ ____________________________________ Name and title/position of evaluator:
Contact telephone number:
Contact e-mail address:
Please evaluate the past performance using only the following ratings without variation. If the rating is other than Fully Acceptable, please provide additional information in the appropriate block or in the remarks section of this form.
S = Superior Performance
V = Very Good with very few issues
F = Fully Acceptable/Good
M = Marginally Acceptable
U = Unacceptable Performance
| Please rate and provide information/comments for the following: |
| Circle/indicate selection |
| Q1. Rate how well the contractor complies with requirements and/or expectations? |
| S V F M U |
| Q2. Rate contractor’s knowledge and expertise in providing on-call neurosurgery services. |
| S V F M U |
| Q3. Rate this contractor’s neurosurgeons. |
| S V F M U |
| Q4. Rate the level of access to the contractor’s personnel. (i.e. Did they respond in a timely manner? Did they meet the requirements of being available and responding as according to the contract?) |
| S V F M U |
| Q5. Rate overall ease of contractor’s scheduling process. |
| S V F M U |
| Q6. Rate how well contractor protects the privacy of patients. |
| S V F M U |
Q9. Would you award another contract to the firm being evaluated? If no, please explain:
Yes No
Additional Remarks: Please use this space to indicate anything else you would like to say about the contractor being referenced or to list anything you especially liked or disliked about this contractor:
| Signature of Evaluator |
| Date |
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