Attachment D.19 Past Performance Survey Amend 0003.docx

36C24925R0056 – Dyersburg CBOC Attachment D.19 – Past Performance Survey

Past Performance Survey

Please have evaluator complete and email directly to Laura Edelman at laura.edelman@va.gov by January 14, 2026 at 10:00AM CT. Surveys will not be accepted if sent by the Offeror.

Name of Offeror Evaluated:

Contract Number:

Evaluator’s Full Name:

Evaluator’s Position held or function in relation to project:

Evaluator’s Company/Organization Name, Address and Phone number:

Evaluator’s email address:

Reference Instructions: Your comments would be appreciated regarding this vendor’s past performance.

Please evaluate the Past Performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, provide additional information in the appropriate block or in the remarks section of this form.

O = Outstanding Performance greatly exceeded contract requirements

A = Above Average Performance exceeded contract requirements

S = Satisfactory Performance met 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

Describe exactly what type of Outpatient Clinic Services or similar service(s) were provided to your company/organization?

Length of the Service (Provide dates):

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

O A S M U

Q2. How timely was the Contractor’s performance when filling medical positions needed?

O A S M U

Q3. Rate the effectiveness of the Contractor’s management of the contract?

O A S M U

Q4. Quality Control: Rate the overall quality of Contractor’s work.

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, explain on the following page.

Yes No

Q9. Would you award another contract to this Contractor? If no, explain on the following page.

Yes No

Q10. Was the customer satisfied with the service provided? If no, explain on the following page.

Yes No

Q11. To what extent did Contractor notify you of problems of potential issues?

O A S M U

Q12. Did the Contractor submit accurate invoices during the performance period?

Yes No

Q14. Did the Contractor respond promptly to requests?

Yes No

Past Performance Survey – Remarks Section

Evaluator’s Additional Remarks regarding services:

Signature of Evaluator:

Print Name of Evaluator: