36C24920Q0162-003.docx

D.2 PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for 36C24920Q0162 for Automated Glycohemoglobin Instrumentation, A1C Testing Supplies & CPRR at the TVHS & Lexington VAMC.

PAST PERFORMANCE INSTRUCTIONS

The Network Contracting Office 9 (NCO 9), Murfreesboro, Tennessee has issued a solicitation to provide 36C24920Q0162 for Automated Glycohemoglobin Instrumentation, A1C Testing Supplies & CPRR at the TVHS & Lexington VAMC.

Past performance information will be used to evaluate proposals received. Section A is to be completed by the offeror. Section A of the enclosed questionnaire 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, Murfreesboro, Tennessee.

The offeror must provide this entire document to each of its assessors. The offeror shall only submit with its proposal (by the closing date of the Solicitation) copies of Section A of the questionnaire as provided to the assessors.

Section B in its entirety is to be completed by the assessor(s). An individual assessor knowledgeable of the contractor’s quality of supplies and services rendered is requested to verify, complete the questionnaire, and submit to the Contracting Office. If evaluating more than one contract for the same contractor, use a separate questionnaire for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing your assessment is greatly appreciated. The questionnaire should be completed as soon as possible but no later than the date and time proposals are due. Assessor is requested to send electronically to LaShanda Harrington at LaShanda.Harrington@va.gov.

Assessor: Please do not send this information to the Offeror being evaluated.

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

PAST PERFORMANCE QUESTIONNAIRE

SECTION A: Contractor Information (to be completed by the contractor for who past performance information is being collected, prior to forwarding to assessors)

1. Prospective Government Contractor ______________________________________

2. Contractor Point of Contact: ___________________________________________

3. Phone number (with area code): ___________________________________________

4. Assessor Contract Award number: _________________________________________

5. Description of Services provided under contract: ________________________________________________________________________

6. Contract award date: ___________ Contract Amount: Initial ___________Final ____

7. Period of Performance or Delivery Date: _________________________

ASSESSOR INFORMATION:

Assessor Name

Title

Phone Number/Email Address

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

(Signature)

SECTION B: Assessors Information (to be completed by assessors.

RATING SCALE Definitions Past Performance Evaluation Ratings

Government has a reasonable expectation that the offeror will successfully perform the required effort, or the offeror’s performance record is unknown. (See note below.)

Government has no reasonable expectation that the offeror will be able to successfully perform the required effort.

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

1. Rate the contractor’s compliance with contractual requirements. A U

2. Overall rating of contractor quality of service. A U

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

SCHEDULE

1. Delivery of service was within required time period specified by contract requirements. A U

2. Rate the contractor’s ability to control cost and submit invoices.

Are invoices complete, accurate, and timely? A U

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

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.) A U

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). A U

3. Rate the contractor's ability to submit required reports and/or invoices in a timely manner. A U

4. Rate the contractor’s responsiveness to customer complaint resolution. A U

5. Overall rating of contractor’s business relations. A U

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

How would you feel about awarding 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.

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

Overall Rating of Contractor’s performance (quality, schedule, business relations,) on contract being assessed.

VII. General Comments:

ASSESSOR:

Identify your role in the contract award or administration and the period of your involvement.

Contract Specialist/Contracting Officer

Technical Project Lead/Project Officer

OTHERS

________________________________________ __________________________ (Signature) (Date)

(Typed or Printed Name) (Organization Name)

(Phone Number)