36C25819R0003-028.docx

CONTRACTOR PERFORMANCE QUESTIONNAIRE

The below-named contractor is being considered for award of a contract for Solicitation No. 36C25819R0003, “Payson Community Based Outpatient Clinic (CBOC)”. The scope of work includes, but is not limited providing primary care and mental health care in a clinic environment to veterans primarily residing in Payson, Arizona and surrounding area. The contractor performing the services shall provide a continuum of care from prevention to diagnosis and treatment, to appropriate referral and follow-up. The contractor’s outpatient site of care must have the necessary professional medical staff, diagnostic testing and treatment capability, and referral arrangements needed to ensure continuity of health care. A primary consideration in our selection process is the contractor’s history of performance of similar efforts. Please make every effort to be as thorough as possible in your answers/ comments. When completed, please return the completed questionnaire via fax or e-mail. You may also e-mail the completed questionnaire if received in Microsoft Word or PDF format to nonya.montano@va.gov or fax to Department of Veterans Affairs, Attn: Nonya Montano, (520) 629-1817.

A. GENERAL INFORMATION

Contractor’s Name: ____________________________________________________________

Address: ____________________________________________________________________

Telephone Number: _____________________ Point of Contact: _______________________

B. RESPONDENT INFORMATION

Name: ________________________________ Title: ______________________________

Organization & Address: ________________________________________________________

Telephone:________________ Fax:__________________ Email:_______________________

C. CONTRACT INFORMATION

Contract Number/Title: ________________________________________________________

Period of Performance: ________________________________________________________

Dollar Amount of Contract: _________________ Type of Contract: ____________________

Services Performed: ___________________________________________________________

Part D: PERFORMANCE INFORMATION

Choose the category on the below scale that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF HIGHLY ACCEPTABLE, MARGINAL OR UNACCEPTABLE.

1 - EXCEPTIONAL: Performance meets contractual requirements and exceeds many to the Government's benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the Contractor were highly effective.

2 - VERY GOOD: Performance meets contractual requirements and exceeds some to the Government's benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the Contractor were effective.

3 - SATISFACTORY: Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the Contractor appear or were satisfactory.

4 - MARGINAL: Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the Contractor has not yet identified corrective actions. The Contractor's proposed actions appear only marginally effective or were not fully implemented.

5 - UNSATISFACTORY: Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the Contractor's corrective actions appear or were ineffective.

Please use the above ratings to describe the contractor’s performance in the following areas:

1. QUALITY OF SERVICE

COMMENTS/REMARKS:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. SCHEDULE

COMMENTS/REMARKS:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. MANAGEMENT

b. Contractor was proactive in keeping you informed of conflicts if they were going to occur 1 2 3 4 5

COMMENTS/REMARKS:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. REGULATORY

COMMENTS/REMARKS:______________________________________________________________

5. If a government contract, did the contractor receive any Contract Discrepancy Reports, Letters of Concern, or Cure Notices? __________ If yes, please describe:

6. If given the opportunity, would you award another contract to this contractor? Please explain response below.

6. OVERALL RATING (Please Circle One):

EXCEPTIONAL VERY GOOD SATISFACTORY MARGINAL UNSATISFACTORY