Attachment 4 - Past Performance Questionnaire.docx

ATTACHMENT 4

36C25719R0027

PAST PERFORMANCE QUESTIONNAIRE

VISN 17 Home Oxygen Services

Please e‐mail the completed questionnaire to: Juan.Martinez4@va.gov Please double-click on boxes to check or uncheck.

CONTRACT IDENTIFICATION

********************** The Contractor Must Fill Out This Section ****************** Part 1:

a. Contractor:

b. Contract number:

c. Contract type:

d. Was this a competitive contract? |_| Yes |_| No

e. Period of performance:

f. Initial contract price: $

g. Current/final contract price: $

h. Potential and actual number of patients served:

i. Description of services provided: (Please include any unusual requirements.)

a) b) c) d)

j. Of those services provided were there significant performance issues in one or more provided services?

k. Number of actual customers (VAMCs) served:

l. Description of services that were sub‐contracted off‐site:

m. Indicate any performance issues with sub‐contracted services?

n. Number of years providing services to VAMCs with patient quantity over 5,500:

o. Largest number of VAMC patient count:

PAST – PERFORMANCE EVALUATION – (Completed by Evaluator)

Please indicate your satisfaction with the contractor’s performance by circling the appropriate letter using the scale provided. This scale is defined as follows:

Performance Confidence Assessment

Excellent/ Based on the offeror’s performance record, essentially no doubt High Confidence exists that the offeror will successfully perform the required effort.

Good/ Based on the offeror’s performance record, little doubt exists Significant Confidence that the offeror will successfully perform the required effort.

Satisfactory/ Based on the offeror’s performance record, some doubt exists that Confidence the offeror will successfully perform the required effort

PERFORMANCE

P1. Completed or complied with all aspects of the contract for the following items:

P2. Contractor maintained accurate data, and provided compliance with procedure coding medical records security, and workload reporting. |_|E |_|G |_|S |_|N |_|U

P3. Contractor provided necessary compliance with computer/communications compliance to meet contract requirements. |_|E |_|G |_|S |_|N |_|U

Provide any explanation you may feel is required to clarify any of the above responses. Provide additional sheets as required:

QUALITY

Q1. Contractor had effective quality control program to ensure contract compliance.

|_|E |_|G |_|S |_|N |_|U

Q2. Contractor demonstrated ability to identify and correct weaknesses in management (relative to contract, personnel (quantity and/or quality), planning/scheduling, and quality of service.

|_|E |_|G |_|S |_|N |_|U

Q3. Contractor demonstrated ability to correct discrepancies in contract performance.

|_|E |_|G |_|S |_|N |_|U

Provide any explanation you may feel is required to clarify any of the above responses. Provide additional sheets as required:

SCHEDULE

S1. Timeliness/effectiveness of providing services without extensive customer guidance.

|_|E |_|G |_|S |_|N |_|U

Provide any explanation you may feel is required to clarify any of the above responses. Provide additional sheets as required:

MANAGEMENT

M1. Contractor provided experienced/qualified management personnel to meet contract requirements. |_|E |_|G |_|S |_|N |_|U

M2. Contractor provided experienced/qualified staff to meet contract requirements.

|_|E |_|G |_|S |_|N |_|U

M3. Contractor resolved customer complaints timely. |_|E |_|G |_|S |_|N |_|U

Part IV Government contracts only: Has/was this contract partially or completely terminated for default, cause or convenience or are there any pending terminations?

Yes |_| Default |_| Convenience |_| Pending Termination |_| No |_|

If yes, explain (e.g., inability to meet price, performance, or delivery schedules, etc.)

Narrative Summary

a. What were the contractor’s greatest strengths in the performance of the contract?

b. What were the contractor’s greatest weaknesses in the performance of the contract?

c. Would you have any reservations about soliciting this contractor in the future or having them perform one of your critical and demanding programs?

d. Are there any other issues not covered you feel important to note about performance of this contractor?

Part V

Considering all the information provided above, please rate the contractor’s performance overall. |_|Exceptional |_|Very Good |_|Satisfactory |_|Neutral |_|Unsatisfactory

Evaluator’s Digital Signature Date Page 1 | 1