ATT D5 PAST PERFORMANCE QUESTIONNAIRE.docx

ATTACHMENT D5- 36C25622Q0570

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, Melanie Hawley, to assess the likelihood that the Contractor will perform successfully on an impending requirement for providing a Pathologist/staffing services for the Southeast Louisiana Veterans Health Care System (SLVHCS). Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME _________________________________________

REFERENCED CONTRACT # _________________________________________

2. Background. The SLVHCS has a requirement for a contractor to provide a staffing service (location New Orleans, LA). The contractor shall provide a Pathologist per the terms and conditions of the Performance Work Statement. Pathologist is required to be credentialed.

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 Cost of Contract:__________________Award/Incentive/Deduction_____________ Any terminations for cause or default? Circle YES or NO If yes, brief explanation:___________________________ Point Of Contact/COR:____________________________ Title:___________________________________ Telephone Number:____________________________ Point of Contact’s email address:______________________

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 properly trained Pathologist (Y/N)? ___________

Q2. If no, please provide a short description of the type of staff provided and to what department they were assigned.

Q3. Did the contractor provide a primary liaison who provided contract administrative support and daily oversight of contractor providers including management of the calls/scheduling.

(Y/N)? ______________. (please provide details if appropriate)

Q4. Would you award to this contractor again? (Y/N)____

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

Rating

Definition

PAST PERFORMANCE QUESTIONNAIRE

FOR OFFICIAL USE ONLY

NOTE: Anything rated higher than Satisfactory or lower than Satisfactory, must be supported by comments.

QUALITY OF SERVICE

1. Contractor's compliance with contractual terms and conditions. E VG S N M U N/A

2. Quality of contractor furnished reports/deliverables including documentation. E VG S N M U N/A

3. Overall rating of contractor's standard of service/patient care. E VG S N M U N/A

4. Contractors ability to meet standards specified for in contract. E VG S N M U N/A

5. Overall rating of contractor's quality of service. E VG S N M U N/A

COMMENTS:

TIMELINESS OF PERFORMANCE

1. Contractor's ability to meet specific response times and scheduled E VG S N M U N/A time frames for completion of service.

2. Contractor's responsiveness/timeliness for providing administrative E VG S N M U N/A reports/documents including documentation required by the contract.

3. Contractor's timeliness in providing work schedule. E VG S N M U N/A

4. Overall rating of contractor's responsiveness/timeliness. E VG S N M U N/A

BUSINESS RELATIONS

1. Contractor's ability to identify problems and potential problems and E VG S N M U N/A promptly notify the Contracting Officer.

2. Contractor's ability to correct problems and prevent or mitigate potential E VG S N M U N/A problems in a timely manner.

3. Contractor's willingness to improve and correct noncompliance issues E VG S N M U N/A or concerns.

4. Extent to which the contractor has demonstrated reasonable and cooperative E VG S N M U N/A behavior.

5. Contractor's ability to use effective approaches and provide technical E VG S N M U N/A expertise and resources to solve contract problems.

6. Contractor's working relationship with the Contracting Officer, E VG S N M U N/A quality assurance personnel and customers.

7. Contractor's flexibility in satisfying the requirements of its customers. E VG S N M U N/A

8. Extent to which the contractor provided prompt and courteous E VG S N M U N/A service when responding to customer complaint.

9. Overall rating of customer satisfaction. E VG S N M U NIA

10. Overall rating of business relations. E VG S N M U N/A

MANAGEMENT OF KEY PERSONNEL

1. Contractor's ability to select and retain cooperative and effective E VG S N M U N/A key personnel (Pathologist).

2. Extent key personnel were knowledgeable about contractual E VG S N M U N/A requirements.

3. Contractor's ability to meet replace with another qualified E VG S N M U N/A personnel in order to continue to provide required services.

4. Contractor's ability to effectively manage contract along their other contracts. E VG S N M U N/A

5. Overall rating of contractor's management of key personnel. E VG S N M U N/A

Any other comments:

Printed Name & Signature of Evaluator

Date

6. Thank you for your time! Please return completed questionnaire DIRECTLY to Melanie Hawley, Contracting Officer for this acquisition, at Melanie.Hawley@va.gov not later than 10 am, Central, June 28, 2022. For any questions, please email her.