36C25018R0234-005.pdf

36C25018R0234 – VISN 10 Ohio Home O2 Services

PAST PERFORMANCE QUESTIONNAIRE

VISN 10 OHIO Home Oxygen Services

36C25018R0234

Please fax, e‐mail or mail the completed questionnaire to:

ATTN: Davina Perry Fax: (216) 447‐8310 Department of Veterans Affairs 6150 Oak Tree Blvd.

Suite 300 Independence, OH 44131 e‐mail: Davina.Perry@va.gov

CONTRACT IDENTIFICATION

********************** The Contractor Must Fill Out This Section ****************** Part 1:

a. Contractor:

b. Contract number:

c. Contract type:

d. Was this a competitive contract? Yes ___________ No ________

e. Period of performance:

f. Initial contract price: $____________________________

g. Current/final contract price: $____________________________

h. Potential and actual number of patients served:

i. Description of services provided: (Please include any unusual requirements.)

a) b) c) d)

j. Of those services provided were there significant performance issues in one or more provided services?

k. Number of actual customers (VAMCs) served:

l. Description of services that were sub‐contracted off‐site:

m. Indicate any performance issues with sub‐contracted services?

PAST – PERFORMANCE EVALUATION

Please indicate your satisfaction with the contractor’s performance by circling the appropriate letter using the scale provided. This scale is defined as follows:

Performance Confidence Assessment

Excellent/ Based on the offeror’s performance record, essentially no doubt High Confidence exists that the offeror will successfully perform the required effort.

Good/ Based on the offeror’s performance record, little doubt exists Significant Confidence that the offeror will successfully perform the required effort.

Satisfactory/ Based on the offeror’s performance record, some doubt exists that Confidence the offeror will successfully perform the required effort

Neutral/ No performance record is identifiable Unknown Confidence “IAW FAR 15.305(a)(2)(iii) & (iv)

Unsatisfactory/ Based on the offeror’s performance record, extreme doubt exists No Confidence that the offeror will successfully perform the required effort.

PERFORMANCE

P1. Completed or complied with all aspects of the contract for the following items:

Initial Home Set‐Up Services E G S N U Equipment Preventive Maintenance E G S N U Emergency Services E G S N U Patient Education Services E G S N U Delivery Services E G S N U Home Visit Services E G S N U Equipment Reliability E G S N U

P2. Contractor maintained accurate data, and provided compliance with procedure coding medical records security, and workload reporting. E G S N U

P3. Contractor provided necessary compliance with computer/communications compliance to meet contract requirements. E G S N U

Provide any explanation you may feel is required to clarify any of the above responses. Provide additional sheets as required:

QUALITY

Q1. Contractor had effective quality control program to ensure contract compliance.

E G S N U

Q2. Contractor demonstrated ability to identify and correct weaknesses in management (relative to contract, personnel (quantity and/or quality), planning/scheduling, and quality of service.

E G S N U

Q3. Contractor demonstrated ability to correct discrepancies in contract performance.

E G S N U Provide any explanation you may feel is required to clarify any of the above responses. Provide additional

SCHEDULE

S1. Timeliness/effectiveness of providing services without extensive customer guidance.

E G S N U

Provide any explanation you may feel is required to clarify any of the above responses. Provide additional

MANAGEMENT

M1. Contractor provided experienced/qualified management personnel to meet contract requirements. E G S N U

M2. Contractor provided experienced/qualified staff to meet contract requirements.

E G S N U

M3. Contractor resolved customer complaints timely. E G S N U

Part IV Government contracts only: Has/was this contract partially or completely terminated for default or convenience or are there any pending terminations?

Yes ____ Default ____ Convenience _____ Pending Terminations ____ No ____

If yes, explain (e.g., inability to meet price, performance, or delivery schedules, etc.)

Narrative Summary

a. What were the contractor’s greatest strengths in the performance of the contract?

b. What were the contractor’s greatest weaknesses in the performance of the contract?

c. Would you have any reservations about soliciting this contractor in the future or having them perform one of your critical and demanding programs?

d. Are there any other issues not covered you feel important to note about performance of this contractor?

Part V

Considering all the information provided above, please rate the contractor’s performance overall.

Exceptional Very Good Satisfactory Neutral Unsatisfactory

Evaluator’s Signature Date