36C25918R0608-002.docx

ATTACHMENT 1 – PAST PERFORMANCE QUESTIONNAIRE

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 Contractor will perform successfully on an impending requirement for the Rocky Mountain Regional VA Medical Center. Your prompt completion and return of this questionnaire is greatly appreciated. Please return this form via email by October 1, 2018.

CONTRACTOR NAME: ____________________________________________

REFERENCED CONTRACT: ________________________________________

2. Background. The Rocky Mountain Regional VA Medical Center has a requirement to provide Intraoperative Neurophysiologic Monitoring Services for the veterans and beneficiaries at the VA in Aurora, Colorado.

3. GENERAL INFORMATION: (Completed by the Reference of Contractor being evaluated). Please include name of organization, name of person completing questionnaire, address, phone number, and email address.

4. Please answer the following questions pertaining to the relevancy of the Intraoperative Neurophysiologic Monitoring Services provided to your organization:

Q1. Did the contractor provide Intraoperative Neurophysiologic Monitoring Services in your facility (Y/N)?

If yes, how many FTE’s did they provide? _________ Q2. If no, please provide a short description of the type of services provided, the number of FTE, and to what department they were assigned. ______________________________________________________________

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, Marginal, or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of the form.

"E" = Excellent Performance greatly exceeded the contractual requirements.

"G" = Good Performance exceeded the contractual requirements.

"S" = Satisfactory Performance met the contractual requirements.

"M" = Marginal Performance met the minimum contractual requirements but some material aspects of the contractor's performance were less than satisfactory.

"U" = Unsatisfactory Performance was poor and/or did not satisfy contractual requirements.

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

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

Q8. Additional comments relating to contractor performance:

Thank you for your time. Please return completed questionnaires to Susan Protho, Contracting Officer, for this acquisition at susan.protho@va.gov no later than October 1, 2018. For any questions, please call Susan at 303-712-5801.