Attachment 3 REVISED.pdf

PAST PERFORMANCE QUESTIONNAIRE

Non-Emergent Wheelchair and Ambulatory Patient Transportation Services

RFQ# 36C25025R0013

PART ONE: INSTRUCTIONS

The company who has provided you with this form is proposing on a Non-Emergent Wheelchair and Ambulatory Patient Transportation Services solicitation. Past Performance is an important part of the evaluation criteria for this acquisition, so your input is very important. Please provide an honest assessment and return the questionnaire to the vendor promptly so the vendor can provide with their solicitation package.

If you have any questions about this request, please contact: Morgan.Stein@va.gov.

PART TWO: GENERAL INFORMATION

1. OFFEROR’S NAME AND ADDRESS: _____________________________________

2. CUSTOMER ORGANIZATION: _____________________________________

CUSTOMER POINT OF CONTACT/EVALUATOR:

NAME: ___________________________________

TITLE: ___________________________________

PHONE NO: ___________________________________

3. Contract Number(s): ___________________________________

4. Contract(s) Value: ___________________________________

5. Period of Performance(s): _________________________________

6. Contract Type: ___________________________________

7. Complexity of Work:

____DIFFICULT ____ROUTINE

8. Brief Description of Your Contract Requirements:

mailto:Morgan.Stein@va.gov

PART THREE: OFFEROR PERFORMANCE RATINGS

On the following pages, please summarize the offeror’s performance in each rating factors. Each factor has a set pf sub-factors with four possible confidence ratings. Determine the adjectival rating that most nearly represents experience with this offeror and indicate assessment by placing an “X” under the appropriate heading.

Adjectival ratings are defined below and should be used as a reference in assessing performance:

RATING DEFINTION

Superior Based on the offeror’s past performance record, it is highly likely that the offeror will successfully perform the required effort

Satisfactory Based on the offeror’s past performance record, it is likely that the offeror will successfully perform the required effort.

Unsatisfactory Based on the offeror’s past performance record, it is not likely that the offeror will successfully perform the required effort.

Neutral No relevant performance record is identifiable upon which to base a meaningful performance rating. A search was unable to identify any relevant past performance information for the offeror, key personnel, or subcontractors. This is neither a negative nor positive assessment.

Superior Satisfactory Unsatisfactory Neutral

Transmission/Connectivity to your IT systems

Quality of IT Support

Startup Time from contract award to contract start date

Test Menus

Turn Around Times

Notification of Specimen Evaluation Viability

Metrics for Critical Results

Specimen Pick-Up Time

Continuing Education Materials (PACE, CME, and

CE)

1. Has this contract been partially terminated for default or convenience?

___ YES ___ Default ___Convenience

___ NO

If yes, please explain (e.g., inability to meet cost, performance, or delivery schedules – also include contract number, name, and phone number of Termination Contracting

Officer – TCO)

2. What was the Contractor’s greatest strength in the performance of the contract?

3. What was the Contractor’s greatest weakness in the performance of the contract?

4. Would you award another contract to this contractor?

____ YES ___NO

COMMENTS:

PART FOUR: EVALUATOR’S CERTIFICATION

I hereby certify that the information in this form is accurate and complete to the best of my knowledge.

SIGNED: ___________________________________________

TITLE: ___________________________________________