36C25918R0573-006.docx

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 an Inpatient Dialysis Service in Oklahoma City, OK for the Oklahoma City VA Medical Center, Oklahoma City, Oklahoma. Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME _________________________________________

REFERENCED CONTRACT # _________________________________________

2. Background. The Oklahoma City VA Medical Center has a need for the provision of Inpatient Dialysis Service services for eligible Veterans. The contractor shall furnish health care providers, equipment and supplies, and administrative functions to fulfill the support of enrolled patients.

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 Primary Care Services and Mental Health 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.

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?

E G S M U

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.

E G S M U

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).

E G S M U

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?

E G S M U

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 Kevin D. Pollard, Contracting Officer for this acquisition, at Kevin.pollard2@va.gov not later than 2:00 pm Central, May 31, 2016. For any questions, please call 405-456-1896.