Past Performance Questionnaire.docx

36C25718R0379

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 Contractor will perform successfully on an impending requirement for the VA North Texas Health Care System (VANTHCS). Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME ______________________________________________

REFERENCED CONTRACT # _______________________________________

2. The VANTHCS requires Community Based Outpatient Clinic (CBOC) services providing Primary Care (PC), space and administrative support to veterans in north Texas.

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

Q1. Did the contractor provide CBOC services to your agency / organization? |Y| |N|

Q2. If no, provide a short description of the type of services the Contractor provided including the number of FTE and/or number of patients served.

5. Please answer questions relating to performance using the following guide.

|E| Excellent Consistent record of exceptional past performance by the offeror. and any proposed major subcontractors on work identical or very similar to the work requirements of the proposed contract. Many strengths and no weaknesses

|V| Very Good Consistent record of successful past performance by the offeror and any proposed major subcontractors on work identical or very similar to the work requirements of the proposed contract. Strengths far outweigh any weaknesses.

|G| Good Successful past performance by the offeror and any proposed major subcontractors on work similar to the work requirements of the proposed contract. Strengths outweigh any weaknesses.

Please provide comments

Circle one

1. Comply with overall contract requirements.

|E| |N|

|V| |P|

|G| |F|

2. Meet all staffing and clinical service requirements.

3. Quality of the providers and services provided by this Contractor in terms of technical competence, reliability, and conduct with patients and staff.

4. Able to meet unexpected and short notice changes and/or requirements (e.g. increase in patient census, training requirements).

5. Contractor’s administrative staff ease of communication with your organization. Contractor’s ability to complete credentialing and privileging, billing and invoicing processes, and overall contract management.

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

Yes No

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

Yes No

8. Additional Comments

Respondent Information:

Name (printed) ____________________________________

Company/ Agency__________________________________

Phone _________________________ FAX: ____________

Position/Title ______________________________________

Contractor Performed as: [] Prime Contractor [] Sub-Contractor

Dollar Amount of contract ____________________________

Dates of Performance _______________________________

6. Thank you for your time. Please return completed questionnaire to the Contracting Officer, carlos.leon@va.gov .