36C25519Q0237-003.docx

PAST PERFORMANCE QUESTIONNAIRE

Network Contracting Office 15 is conducting a competitive acquisition against the Federal Business Opportunities market for the following service types:

1. Registered Nurses (RNs),

2. Licensed Practical/Vocational Nurses

3. Certified Nursing assistants (CNA), no guarantee of a 40-hour work week.

SIN 621-I 621-025

The offeror has identified you as a reference to validate the offeror’s past performance. Please complete the following questionnaire to assist our evaluation of the contractor’s past performance and return no later than 09:00 a.m., CST, MM/DD/YY to Colleen Donahue-MacDonald, NCO 15, Fax 913-946-1198 or e-mail at colleen.donahue-macdonald@va.gov.

Name of Contractor being evaluated: ________________________________

1. How long has your company has this contract/BPA with this contractor? __________________

2. Type of service being provided: ___________________________________________

3. Where is the service being provided? _______________________________________

4. What is the total value of this contract/BPA?: ________________________________

5. How many Full Time Equivalents (FTE) are being provided under this contract/BPA?:

6. Would you award another contract/BPA to this contractor? Yes______ No _____ If no, please provide an explanation:

7. What average length of time did it take to place a provider in your facility from the time a vacancy was announced and the length of stay by that provider in that position? Please explain any delays in providing documentation for credentialing, etc.:

8. How would you rate the quality of the medical providers supplied?

Exceptional _____Very Good, _____Satisfactory, _____, Marginal, _____, Unacceptable If less than “Satisfactory” Please provide explanation:

9. How would you rate the Business/Customer Relationship with the Contractor? (Concern for customer’s interest successfully managed services; reasonable/cooperative behavior) Exceptional _____Very Good, _____Satisfactory, _____, Marginal, _____, Unacceptable

10. Please provide any other examples or comments concerning the contractor’s performance that would be relevant in assessing the probability of successful contract performance:

Rating System:

Exceptional: Performance meets the contractual requirements and exceeds many to the contractor’s benefit. The contractual performance was accomplished with few minor problems for which corrective action taken was highly effective.

Very Good: Performance meets contractual requirements and exceeds some to the contractor’s benefit. The contractual performances was accomplished with some minor problems for which corrective action taken was effective.

Satisfactory: Performance meets contractual requirements. The contractual performance was accomplished with some minor problems for which corrective action taken appears or was satisfactory.

Marginal: Performance does not meet some contractual requirements. The contractual performance reflects a serious problem for which the contractor has identified some corrective actions. The proposed actions appear only marginally effective or have not been fully implemented.

Unacceptable: Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance contains serious problems of which the contractor has identified corrective actions. The proposed actions appear or were ineffective.

Your Name: ________________________ Your Title: ______________________

Your Phone number: ________________ Your Fax: ______________________

Your e-mail address: _____________________________________________________