36C25820Q0026-006.docx

Solicitation 36C25820Q0026, Health Care for Homeless Veterans (SAVAHCS), Attachment 5

ATTACHMENT 5 - PAST PERFORMANCE QUESTIONNAIRE

The below-named contractor is being considered for award of a Contract for Solicitation No. 36C25820Q0026 for Health Care for Homeless Veterans (thereafter referred to as HCHV) services to be furnished to the Department of Veterans Affairs Medical Center (VAMC), servicing the Southern Arizona VA Health Care System (SAVAHCS), Tucson, Arizona. Network Contract Office (NCO) 22-G intends to award a non-personnel services Contract to provide care, treatment, and rehabilitative services, including case management services; and therapeutic transitional housing assistance for the HCHV programs.

A primary consideration in our selection process is the contractor’s history of performance of similar efforts. PLEASE COMPLETE THIS FORM and RETURN VIA EMAIL TO: Aaron.Davis@va.gov, Contract Specialist/Contracting Officer, (520) 629-4611. FORMS MUST BE RECEIVED BY THE CONTRACTING OFFICER NOT LATER THAN DECEMBER 2, 2019 (2:00 pm, Mountain Standard Time) or as otherwise specified on the Solicitation/Contract/Order for Commercial Items, Standard Form 1449, Block 8, Offer Due Date/Local Time.

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: ________________ Current Dollar Amount of Contract: ___________ Services Performed: ____________________________________________________________

D. PERFORMANCE INFORMATION

Choose the category on the below scale that most accurately describes the contractor’s performance or situation.

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

1. MANAGEMENT EFFECTIVENESS

COMMENTS/REMARKS:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. QUALITY OF SERVICE AND WORKMANSHIP

COMMENTS/REMARKS:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. TIMELINESS/ADHERENCE TO SCHEDULES

COMMENTS/REMARKS:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. CUSTOMER SATISFACTION

COMMENTS/REMARKS:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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

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