36C25720Q0225-005.docx

PAST PERFORMANCE EVALUATION FORM

IN REFERENCE TO: DEPARTMENT OF VETERANS AFFAIRS (NCO-17)

SOLICITATION: 36C25720Q0225

“TELEMENTAL HEALTH SERVICES IN SOUTH TEXAS”

ORGANIZATION NAME: ___________________________________________________________________________

NAME OF EVALUATOR:

EVALUATOR’S ORGANIZATION NAME:

EVALUATOR’S ORGANIZATION ADDRESS:

EVALUATOR’S PHONE NUMBER:

EVALUATOR’S EMAIL ADDRESS:

EVALUATOR’S CONTRACT NUMBER AND SHORT DESCRIPTION OF THE WORK PERFORMED BY THE COMPANY BEING EVALUATED: __________________________________________________________________________________ Below, provide your overall rating, which indicates your level of confidence in the above named company’s ability to successfully perform based on your experience. Your confidence level must be based on the company’s quality, timelines, and compliance with contract terms and conditions on previous and current contracts of which your organization has been a party.

[ ] HIGHLY CONFIDENT

[ ] SIGNIFICANT CONFIDENCE

[ ] SATISFACTORY CONFIDENCE

[ ] LITTLE CONFIDENCE

[ ] NO CONFIDENCE

[ ] UNKNOWN CONFIDENCE

Would you hire this contractor again; why or why not? ____________________________________________ Please return completed Evaluation Form to Christine Bennett, Contract Specialist via email at Christine.Bennett2@va.gov no later than March 13, 2020.