D.5 - Past Performance Survey-QuestionnaireR1.docx
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- Solicitation number
- 36C24926R0007
About this file
This is a Past Performance Survey Questionnaire template for evaluators to assess contractor performance on the VISN 9 Tele-Radiology Services contract (36C24926R0007). The survey must be completed by independent evaluators and submitted directly to the Contracting Officer Carol Franklin (carol.franklin@va.gov) and Contract Specialist Ramona Bonness (ramona.bonness@va.gov) by May 8, 2026 at 10:00 AM Central Time. Surveys submitted by offerors will not be accepted.
The questionnaire requests evaluator information and focuses on assessing past performance of contractors who have provided outpatient clinic services or similar temporary medical staffing services. Evaluators rate contractor performance across 14 questions using a five-point scale (Outstanding, Above Average, Satisfactory, Marginal, Unacceptable) or yes/no responses. Key evaluation areas include compliance with contract requirements, timeliness in filling medical positions, contract management effectiveness, quality control, flexibility, reliability, responsiveness to technical direction, invoice accuracy, and customer satisfaction. The survey also inquires whether cure notices, show cause letters, suspension of payment, or termination actions were issued, and whether the evaluator would award another contract to the contractor. A remarks section allows for additional comments, particularly when ratings fall below satisfactory levels.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24926R0007 0004.docx | DOCX document | |
| 36C24926R0007 0003.docx | DOCX document | |
| 36C24926R0007 0002.docx | DOCX document | |
| D.3 - CONFLICT OF INTEREST CERTIFICATION STATEMENTR1.pdf | ||
| RFQ 36C24926R0007 Questions and Answers.docx | DOCX document | |
| 36C24926R0007 0001.docx | DOCX document | |
| D.3 - CONFLICT OF INTEREST CERTIFICATION STATEMENT.pdf | ||
| D.2 - CONTRACTOR CERTIFICATION IMMIGRATION AND NATIONALITY ACT OF 1952 AS AMENDED.pdf | ||
| D.5 - Past Performance Survey-Questionnaire.docx | DOCX document | |
| D.1 QASP TELRADIOLOGY CONTRACTORS.docx | DOCX document | |
| 36C24926R0007.docx | DOCX document | |
| D.4 - VHA Teleradiology Handbook.docx | DOCX document |
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Text version
ATTACHMENT D:5 TELERADIOLOGY SERVICES 36C24926R0007
36C24926R0007 – VISN 9 Tele-Radiology Services Attachment D.5 – Past Performance Survey
Past Performance Survey
Please have evaluator complete and email directly to the Contracting Officer Carol Franklin at carol.franklin@va.gov and the Contract Specialist (preferred) Ramona Bonness at ramona.bonness@va.gov by May 8, 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):
| Rate the following questions if the company provided temporary medical staffing or similar services. Provide information/comments in the Remarks Section below. |
| Highlight One |
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
| Q13. Was the Contractor professional and courteous in its interaction with you? |
| 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:
File details come from the government source that posted it. Updated .