36C25618U0479-002.doc

ATTACHMENT A

PAST PERFORMANCE QUESTIONNAIRE

REFERENCE INSTRUCTIONS: The Central Arkansas Veterans Healthcare System (CAVHS) is considering the Offeror listed below for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. The intent of this form is to evaluate the offeror’s services. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation prohibits the release of the names of individuals providing reference information about Offeror’s past performance. This survey should be completed by evaluator’s with sufficient familiarity of the offeror’s performance and returned to the contracting office by the evaluator no later than the closing date, 9/21/2018 at 10a.m. Central Time, of the solicitation by e-mail to jacqueline.simpson3@va.gov Include the solicitation number on the subject line of all e-mails. Solicitation Number: 36C25618U0479 Offeror’s Name: ________________________ Offeror’s e-mail: __________________________________

Request for Proposal: _________________________________________________________________ Name of Person Completing the Evaluation: ______________________________________________ Telephone: __________________ E-mail: _____________________________ Title: _______________________________________

Company/Organization: __________________________________________

Please rate the offeror in each of the following areas. Note: there is room for comments where you deem remarks would be helpful to our evaluation.

· Not Applicable: N/A

· 1: Performance clearly below the contract performance standard or requirement

· 2: Performance occasionally does not meet minimum contract performance standard or requirement

· 3: Performance that meets the minimum contract performance standard or requirement

· 4: Performance that meets and occasionally exceeds the contract performance standard or requirement

· 5: Performance that almost always exceeds the contract performance standard or requirement

1. Overall quality/satisfaction

Overall satisfaction with the Offeror’s performance. Would you (the reference) choose to work with this offeror again?

Delivery performance includes delivery consistency, on time performance, and flexibility in responding to emerging issues and implementing required solutions.

3. Satisfaction with the quality of service delivered

Rate the effectiveness and applicability of the plans and strategies delivered and the actual implementation of those.

4. Satisfaction with problem resolution

This includes the offeror’s ability to solve problems, the speed in which they handle problems, and their effective delivery of resolutions.

5. Satisfaction with the quality of contractor personnel

Rate the quality of the contractor’s staff in executing the project work scope.

6. Have you issued a cure notice, show cause notice, suspension of progress payments or other letters directing the correction of a performance problem in the past 3 years?

Yes No If Yes, please explain.

7. Have you terminated this contractor for default within the past 3 years, or are there any pending termination actions?

Yes No If Yes, please explain.

8. Based on the offeror’s overall performance, would you award them another contract?

Yes No If No, please explain.

9. Have you discussed any adverse past performance problems with the Offeror and given them an opportunity to comment?

Yes No Please explain.

10. Do you file past performance information in a database that the Contracting Officer may search?

Yes No Please explain.

11. If the contract had options, were those options exercised?

Yes No Please explain.

12. List the dates of the contract period of performance (when were services provided)?

13. What was the dollar value of the contract performed by the offeror?

14. Provide a brief description of the services provided by the offeror for this contract.

Please attach any past performance database reports or other material you deem appropriate to a full understanding of the Offeror’s past performance by the evaluator.