36C25019R0051-028.pdf

Solicitation 36C25019R0051 Attachment D.6 – Past Performance Survey

PAST PERFORMANCE SURVEY

Offeror’s Name: ___________________________________________________

Contract Number: __________________________________________________

Contract Type and Dollar Value: _______________________________________

Brief Description of Work: _____________________________________________________________________

“O” =Outstanding = Performance greatly exceeded the contract requirements “A” =Above Average = Performance exceeded the contract requirements “S” = Satisfactory = Performance met the 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 Please rate and provide information and detailed comments for the following: Circle one

1. To what extent did the contractor comply with contract requirements? O A S M U

2. If reports were required, were they accurate in meeting contract requirements? O A S M U

3. To what extent did the contractor use appropriate personnel for contract requirements? O A S M U

4. To what extent did the contractor display technical expertise? O A S M U

5. To what extent was contractor able to meet the performance schedule? O A S M U

6. To what extent was contractor flexible in responding to changing needs? O A S M U

7. To what extent was the contractor reliable? O A S M U

8. To what extent was the contractor responsive to technical directions? O A S M U

Solicitation 36C25019R0051 Attachment D.6 – Past Performance Survey

Your assistance is requested by the Contracting Office to assist with establishing the performance history for the Company (Offeror) named above. In efforts to expedite receipt of the requested information, please email the complete past performance questionnaire(s) to:

Karen.Williams4@va.gov

9. To what extent did contractor notify you of problems or potential problems? O A S M U

10. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, please explain.

Yes No

11. Would you award another contract to the party being evaluated? If no, please explain:

12. Was the customer satisfied with the end product? If no, please explain:

Describe the volume of teleradiology services the offeror provided your firm and please include any other additional comments. (Use additional pages as required)

Explanation of overall rating given:

Name/Title of Evaluator:________________________________________________

Signature of Evaluator:_____________________________________________

Company:________________________________________________________

Telephone No.:____________________________________________________

Email:____________________________________________________________

Date:____________ mailto:Karen.Williams4@va.gov