D5 PAST PERFORMANCE QUESTIONNAIRE.docx

ATTACHMENT D5 – PAST PERFORMANCE QUESTIONNAIRE

1. The Contractor identified below has requested that you complete a past performance questionnaire on their behalf. This questionnaire will be used by the Contracting Officer to assess the likelihood that the Offeror will perform successfully on an impending requirement for a Community Based Outpatient Clinic in Columbus, MS for the Department of Veterans Affairs, G.V. (Sonny) Montgomery VA Medical Center (VAHS), Jackson, Mississippi. Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME

REFERENCED CONTRACT #

2. Background. Department of Veterans Affairs, G.V. (Sonny) Montgomery VA Medical Center (VAHS), Jackson, Mississippi, has a need for the provision of Primary Care services for eligible Veterans living in Lowndes County and the surrounding counties of Mississippi. The contractor shall furnish health care providers, medical facilities, equipment and supplies, and administrative functions to fulfill the support of enrolled patients.

3. GENERAL INFORMATION: (Completed by Reference of Contractor being evaluated) Name of Government or Commercial Organization:

Address:

Contract Number: Brief Description:

Contractor Performed as:

Prime Contractor Sub-Contractor Dates of Performance (if current include expiration): Total Value of

Contract:

Any terminations for cause or default? Circle YES or NO If yes, brief explanation:

Any contract discrepancy reports filed? Circle YES or NO If yes, brief explanation:

Point Of Contact/Contracting Officer’s Representative: Title:

Telephone Number:

Point of Contact’s email address:

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4. Please answer the following questions pertaining to the relevancy of the services provided to you as compared to the description in paragraph 2.

Q1. Did the contractor provide Primary Care Services? (Y/N)?

Q2. If no, please provide a short description of the type of services provided.

Q3. Did the contractor provide any additional services (Y/N)? If so, what types?

5. Please use the below matrix to answer questions relating to performance using the following template.

Please evaluate the past performance using only the following ratings without variation. If the rating is Excellent, Good, Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form.

“S” = Satisfactory = Performance met the contract requirements

were less than satisfactory

“U” = Unsatisfactory = Performance was poor and/or did not satisfy contract requirements

Please write in “not applicable” or “neutral” if unable to rate a certain question. For any E, G, M, or U rating please provide a short summary explanation of rating.

Q6. Did you issue any cure notices, show cause letters, or suspension of payment? If yes, please explain.

Yes

No

Q7. Would you award another contract to the Contractor being evaluated? If no, please explain:

Yes

No

Q8. Additional Comments pertaining to contractor performance:

Printed Name & Signature of Evaluator

Date

6. Thank you for your time. Please return completed questionnaire to Corey Labbe, at corey.labbe@va.gov.

Prior to thew time specified in block 8 of the SF1449 to be considered for award. .

GEN030.09.03.15

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