36C25520R0005-004.docx

PAST PERFORMANCE QUESTIONNAIRE

SOLICITATION NUMBER — 36C25520R0005, Beneficiary Ambulance Transportation Services.

I. Please complete this questionnaire. For assistance with this form or to request an electronic copy, please notify the contract specialist listed at the address below. Handwritten responses will be accepted. If you need more space than provided, please attach additional pages or write on the back. Please include only relevant information. Responses will be treated as source selection sensitive information. Please submit this information on or before the proposal due date as stated on the front of the Standard Form 1449. Return the completed questionnaire either by mail, fax or email to the following address:

Network Contracting Office (NCO) 15 ATTN: Frank Novello 3450 South 4th Street Trafficway Leavenworth, KS 66048 Telephone: (913) 946-1962 E-mail: frank.novello@va.gov

II. EXPLANATION OF CODES:

CODE PERFORMANCE LEVEL

E EXCELLENT — Performance meets contractual requirements and exceeds many (requirements) to the Government’s benefit. The contractual performance of the element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

G GOOD — Performance meets contractual requirements and exceeds some (requirements) to the Government’s benefit. The contractual performance of the element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

A ACCEPTABLE — Performance meets contractual requirements. The contractual performance of the element being assessed contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

M MARGINAL — Performance does not meet some contractual requirements. The contractual performance of the element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented.

U UNSATISFACTORY — Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

N NOT APPLICABLE — Unable to provide a score. Performance in this area not applicable to the effort assessed.

Attachment (2) - Past Performance Questionnaire 36C25520R0005

Page of 4

THE FOLLOWING IDENTIFYING INFORMATION AND PAST PERFORMANCE ASSESSMENT:

PAST PERFORMANCE QUESTIONNAIRE RFP NUMBER: 36C25520R0005

TITLE: Beneficiary Ambulance Transportation Services SECTION I: OFFERORS SHALL COMPLETE requested information, and in turn, provide the questionnaire to the appropriate Respondent for each source of Past Performance Information mentioned in its Offer. The Respondent must have significant familiarity with the selected contract or subcontract, in order to provide informed answers and comments about various aspects of the past performance.

NAME OF OFFEROR BEING EVALUATED

COMPANY NAME OF PAST PERFORMANCE SOURCE

CONTRACT NUMBER and DATES OF SERVICE FOR WHICH PAST PERFORMANCE INFORMATION IS BEING PROVIDED

DESCRIPTION OF SERVICE

SECTION II: RESPONDENT(S) SHALL COMPLETE the requested information concerning the past performance of the above-named Offeror relative to the contract effort stated. Respondent shall return the completed form directly to the Contracting Officer by email to frank.novello@va.gov.

NAME OF RESPONDENT

TITLE/POSITION

SIGNATURE

ASSESSMENT ELEMENTS: Place an “X” in the appropriate box next to the letter for each item on the questionnaire. Narrative statements are vital. Please provide a supporting narrative for each area. Attach additional pages if there is insufficient space in the comment space.

(A). QUALITY OF SERVICE

1. Did the contractor comply with all contract requirements? Yes No Comments:

2. With regard to timeliness of performance, were turnaround times of the contract met (i.e. completion of administrative requirements, task orders, milestones, and production and delivery requirements?

Yes No Comments:

3. Was the contractor's work found to be accurate and technically/clinically excellent? Yes No Comments:

4. How would you rate the quality of the contractor's end products furnished under this contract?

Excellent Good Acceptable Marginal Unsatisfactory Comments:

5. How would you rate the quality of the contractor's customer service furnished under this contract?

Excellent Good Acceptable Marginal Unsatisfactory Comments:

(B) BUSINESS RELATIONS

6. Was contract Management efficient and responsive?

Always Most of the time Sometimes Never Comments:

7. Did the contractor exhibit reasonable, cooperative behavior and effective communication(s)?

Always Most of the time Sometimes Never Comments:

8. How would you rate the contractors billing timeliness and accuracy?

Excellent Good Acceptable Marginal Unsatisfactory Comments:

9. Was the contractor flexible?

Always Most of the time Sometimes Never Comments:

10. Did the contractor recommend effective solutions to problems?

Always Most of the time Sometimes Never Comments:

11. Did the contractor exhibit a business-like concern for the interests of your Agency or Business:

Always Most of the time Sometimes Never Comments:

(C) CUSTOMER SATISFACTION

12. How would you rate the contractor on the basis of customer (end-user) satisfaction?

Excellent Good Acceptable Marginal Unsatisfactory Comments:

13. Would you select this firm again?

Yes No Comments:

14. How would you rate the contractors timeliness in responding to phone calls and e-mails?

Excellent Good Acceptable Marginal Unsatisfactory

End of Section II

THE COMPLETED PAST PERFORMANCE REFERENCES MUST REACH THE CONTRACTING OFFICE BY THE DATE AND TIME OFFERS ARE DUE. THE GOVERNMENT BEARS NO RESPONSIBILITY TO ASSURE QUESTIONNAIRES ARE PROPERLY RECEIVED.