36C25019R0093-002.pdf

PROCUREMENT SENSITIVE

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ATTACHMENT D1 ‐ PAST PERFORMANCE QUESTIONNAIRE

MESSAGE TO THE EVALUATOR: Your assistance is requested by Lisa Bailey, Contract Specialist, to assist with establishing the performance history for the Company (Offeror) named below. In efforts to expedite receipt of the requested information, the Contract Specialist respectively requests you do not mail hard copies. Instead, please email the complete past performance questionnaire(s) to: Lisa.Bailey12@va.gov. If enough space is not provided, please attach additional information to this questionnaire.

PAST – PERFORMANCE EVALUATION

Part I

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: $____________________________

CUSTOMER OR AGENCY IDENTIFICATION

a. Customer or agency name:

b. Customer or agency description (if applicable):

c. Geographic description of services under this contract, i.e., local, nationwide, worldwide, other commands:

EVALUATOR IDENTIFICATION

a. Evaluator’s name:

b. Evaluator’s title:

c. Evaluator’s phone/fax number:

d. Number of year’s evaluator worked on subject contract:

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

Performance Assessment

Rating Description

Outstanding (O) / High Confidence

(HC)

The Offeror’s performance met contractual requirements and exceeded many requirements to the client’s/agency’s benefit.

The contractual performance was accomplished with few minor problems for which corrective actions taken by the offeror were highly effective.

Acceptable (A) / Confidence (C)

The Offeror’s performance met contractual requirements and exceeded some requirements to the client’s/agency’s benefit.

The contractual performance was accomplished with some minor problems for which corrective actions taken by the offeror were effective.

Marginal (M) / Little Confidence

(LC)

The Offeror’s performance somewhat met contractual requirements. The contractual performance contained problems for which corrective action was taken by the offer and the actions appeared to be resolved marginally.

Unacceptable (U) / No Confidence

(NC)

Performance did not meet contractual requirements. The contractual requirements reflected a serious problem for which the offeror has yet to identify corrective actions or the offeror proposed actions that were not fully implemented.

PERFORMANCE

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

Patient Consultation U M A O Treatment Plan U M A O Treatments U M A O Follow Up Examination U M A O Emergency Treatment U M A O Clinics U M A O Treatment Approval U M A O

P2. Contractor maintained accurate data, and provided compliance with procedure coding, medical records security and workload reporting. U M A O

P3. Contractor provided necessary compliance with computer/communications compliance to meet contract requirements U M A O

P4. Contractor provided necessary physical facility and environment of care U M A O Provide any explanation you may feel is required to clarify any of the above responses:

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QUALITY

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

U M A O

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.

U M A O

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

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

SCHEDULE

S1. Timeliness/effectiveness of patient scheduling without extensive customer guidance.

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

MANAGEMENT

M1. Contractor provided experienced/qualified management personnel to meet contract requirements U M A O

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

U M A O

M3. Contractor resolved customer complaints timely U M A O

Part III 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?

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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 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.)

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

U M A O

Evaluator’s Signature Date