36C25718Q9565-005.docx

ATTACHMENT 2: PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for Clinical Massage Therapist Services, North Texas VA healthcare System, NCO 17

PAST PERFORMANCE INSTRUCTIONS

The NCO 17 Network Contracting Office, Duncanville, TX has issued a solicitation to provide Clinical Massage Therapist Services for the North Texas VA Healthcare System, Dallas Texas.

Past performance information will be used to evaluate proposals received. Section A is to be completed by the Offeror. Section A of the enclosed questionnaire lists the contractor who has identified your office as a source to evaluate their past performance. Section A also authorizes release of this information to NCO 17 Network Contracting Office, Duncanville, Texas.

The Offeror must provide this entire document to each of its assessors. The Offeror shall only submit with its proposal (by the closing date of the Solicitation) copies of Section A of the questionnaire as provided to the assessors.

Section B in its entirety is to be completed by the assessor(s). An individual assessor knowledgeable of the contractor’s quality of services rendered is requested to verify, complete the questionnaire, and submit to the Contracting Office. If evaluating more than one contract for the same contractor, use a separate questionnaire for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing your assessment is greatly appreciated. The questionnaire should be completed as soon as possible but not later than September 7, 2018. Assessor is requested to send electronically to toni.clendenen@va.gov. Reference the Solicitation Number in the Subject Line of the email : Please so not send this information to the Offeror being evaluated.

Thank you in advance for your cooperation and expeditious response to this request.

PAST PERFORMANCE QUESTIONNAIRE

SECTION A: Contractor Information (to be completed by the contractor for who past performance information is being collected, prior to forwarding to assessors)

Solicitation Number

Project/Requirement

1. Prospective Government Contractor’s______________________________________

2. Contractor Point of Contact: ___________________________________________

3. Phone number (with area code):___________________________________________

4. Assessor Contract Award number: _________________________________________

5. Description of Services provided under contract: ________________________________________________________________________

6. Contract award date: ___________ Contract Amount: Initial ___________Final ____

7. Period of Performance or Delivery Date: _________________________

ASSESSOR INFORMATION:

Assessor Name

Title

Phone Number/Email Address

8. Authorization is hereby granted to provide the information requested in this questionnaire to NCO 17 Network Contracting Office

(Signature)

SECTION B: Assessors Information (to be completed by assessors.

RATING SCALE Definitions Past Performance Evaluation Ratings

Acceptable (A) Based on the offeror’s performance record, the Government has a reasonable expectation that the offeror will successfully perform the required effort, or the offeror’s performance record is unknown. (See note below.)

Unacceptable (U) Based on the offeror’s performance record, the Government has no reasonable expectation that the offeror will be able to successfully perform the required effort.

The questions on the survey (see below) shall be rated in accordance with the definitions provided in the Rating Scale. Any unsatisfactory or marginal rating shall be supplemented with an explanation in the space provided.

PAST PERFORMANCE QUESTIONNAIRE

A. OFFEROR’S INFORMATION

Company/Organization Name:

Address:

Point of Contact (POC):

Telephone Number:

Email Address:

B. RESPONDENT INFORMATION

Company/Organization Name:

Address:

Telephone Number:

Point of Contact:

Title of POC

C. CONTRACT INFORMATION

Contract Number:

Task Order Number(s) (If applicable) within three (3) years from date of solicitation:

Type of Contract:

Performance Period: (Base plus any options)

Total Award Dollar Amount:

(Base plus any options)

Contract Description (Ancillary)

A. Performance and Supportability:

(1) The contractor provided quality service that adhered to contract requirements, specifications and standards of professional conduct.

(2) The contractor successfully achieved fill rates established in the contract.

(3) The turnover rate in ancillary labor categories and key personnel was minimal, did not adversely affect contractor performance and minimized Contractor recruiting costs.

(4) The Contractor consistently responded to problems and took appropriate action to correct performance.

B. Management

(1) Contractor was able to resolve customer complaints quickly and effectively.

(2) Contractor demonstrated an overall effective and quality management effort.

(3) Contractor cooperated with the Government in providing flexible, proactive and effective solutions to critical contract issues.

C. Timeliness/Schedule:

(1) Contractor demonstrated ability to plan for and provide replacement candidates during the life of the contract to include pre-planned absences, unplanned illnesses or an extended leave of absence.

(2) The Contractor consistently demonstrated an ability to quickly recruit and retain quality HCPs in accordance with contract requirements and to avoid disruption of services and/or work schedule.

(3) Background Investigation packages (to include current and complete information) were presented in timely fashion to the applicable agency.

Section D. Other:

(1) Would you award this firm another contract? ( ) Yes or ( ) No If you answered “No” provide an explanation. ____________________________________________________________________________________________________________________________________________________________

(2) Was the contract terminated for default or cause? ( ) Yes or ( ) No If you answered “Yes” provide an explanation. ____________________________________________________________________________________________________________________________________________________________

(3) Has the Contractor been given a cure notice, show cause notice, suspension of progress payments in the last three (3) years? ( ) Yes or ( ) No If you answered “Yes”, provide an explanation, how many actions and if they were resolved:

(4) Additional Comments:

ASSESSOR:

Identify your role in the contract award or administration and the period of your involvement.

Contract Specialist/Contracting Officer

Technical Project Lead/Project Officer

OTHERS

________________________________________ _______________________________ (Signature) (Date)