36C25718Q0222-004.pdf

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PAST PERFORMANCE SURVEY

RFQ 36C257-18-Q-0222

The Department of Veterans Affairs Network Contracting Office 17 is conducting a competitive acquisition.

The offeror has identified you as a reference to validate the offeror’s past performance. Please complete the following survey to assist our evaluation of the contractor’s past performance and return no later than 4:00 pm

CST, January 3, 2018, to Sandy Archuleta, NCO 17 Temple, TX via email at sandra.archuleta@va.gov.

Name of Contractor being evaluated: _________________________________________________________

1. How long has your company had a contract with this contractor? ________________________________

2. Type of services being provided? _________________________________________________________

3. Where is the location where services are provided? ___________________________________________

4. What is the total value of the contract? _____________________________________________________

5. How may Full Time Equivalents (FTE) are being provided under the contract? _____________________

6. What is the average length of time it took to place a provider in your facility from the time of award? Please explain any delays in providing documentation for credentialing, background investigations, etc.

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

Exceptional______ Very Good______ Satisfactory______ Marginal______ Unacceptable______

If less than less than satisfactory please provide an explanation:

8. 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______

If less than less than satisfactory please provide an explanation:

9. Would you award another contract to this contractor? Yes______ No______ mailto:sandra.archuleta@va.gov

ATTACHMENT 3

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 contractual requirements and exceeds many to the customer’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 customer’s benefit. The contractual performance was accomplished with some minor problems for which corrective action taken were effective.

Satisfactory: Performance meets contractual requirements. The contractual performance contains some minor problems for which corrective action taken appear or were satisfactory.

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

Unsatisfactory: Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractor performance contains serious problem(s) for which corrective actions appear or were ineffective.

Signature________________________________ Date_____________________

Printed Name_____________________________

Organization_____________________________

Title____________________________________

Telephone_______________________________

Email Address____________________________