36C25918Q0342-003.pdf

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 Offeror will perform successfully on an impending requirement for the Grand Junction VA Medical Center, Grand Junction, CO. Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME _________________________________________

REFERENCED CONTRACT # _________________________________________

2. Background. The Contractor shall provide one (1) FTE Registered Respiratory Therapist Services to Outpatient and Inpatient Veterans on site in accordance with the specifications contained herein to beneficiaries of the Department of Veterans Affairs (VA) and the Grand Junction Veterans Health Care Services (GJVHCS). This locum tenens Registered Respiratory Therapist will fill temporary staffing shortages and is categorized as Professional and Allied Healthcare Staffing Services under SIN 621-034 using WNSC BPAs for Nursing and Allied Health Staffing.

3. GENERAL INFORMATION: (Completed by Reference of Contractor being evaluated)

Name of Government or Commercial Organization:______________________________

Address:_________________________________

Contract Number:______________________________

Brief Description:_________________________________________________________

Contractor Performed as: Prime Contractor Sub-Contractor

Dates of Performance (if current include expiration):_____________________________

Total Value of Contract:__________________

Any terminations for cause or default? Circle YES or NO

If yes, brief explanation:_________________________________________________________________

Any contract discrepancy reports filed? Circle YES or NO

If yes, brief explanation: ________________________________________________________________

Point Of Contact/Contracting Officer’s Representative:________________________________

Title:___________________________________

Telephone Number:____________________________

Point of Contact’s email address:____________________________

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

Q1. Did the contractor provide Respiratory Therapist services (Y/N)? ___________

Q2. If no, please provide a short description of the type of services provided.

Q3. Did the contractor provide any additional services (Y/N)?_________ If so, what types?

5. Please use the below matrix to answer questions relating to performance using the following template.

Please evaluate the past performance using only the following ratings without variation. If the rating is Excellent, Good, Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form.

“E” = Excellent = Performance greatly exceeded the contract requirements

“G” = Good = Performance exceeded the contract requirements

“S” = Satisfactory = Performance met the contract requirements

“M” = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory

“U” = Unsatisfactory = Performance was poor and/or did not satisfy contract requirements

Please write in “not applicable” or “neutral” if unable to rate a certain question. For any E, G, M, or U rating please provide a short summary explanation of rating.

Please rate and provide information/comments for the following: Circle one

Q1. To what extent did the contractor comply with overall contract requirements?

E G S M U

Q2. How successful was the Contractor in filling all requirements?

Q3. How would you rate the quality of the Physicians provided by this Contractor in terms of technical competence, reliability, and demeanor with patients and staff.

Q4. To what extent was the Contractor able to meet unexpected and short notice changes and/or requirements (e.g. unexpected shift vacancies, training requirements).

Q5. How would you rate the Contractor’s administrative staff as pertains to communication with your organization’s key personnel, their ability to complete credentialing and privileging, billing and invoicing processes, and overall contract management?

Q6. Did you issue any cure notices, show cause letters, or suspension of payment? If yes, please explain.

Yes No

Q7. Would you award another contract to the Contractor being evaluated? If no, please explain:

Yes No

Q8. Additional Comments pertaining to contractor performance:

Printed Name & Signature of Evaluator

Date

6. Thank you for your time. Please return completed questionnaire to Laura G. Watts, Contracting Officer for this acquisition, at Leigh.nunn2@va.gov not later than 3:00 pm CST on March 27th, 2018. For any questions, please call 405-456-5113.