36C26118Q9254-004.docx

Past Performance Survey

Reference Instructions: The Department of Veterans Affairs is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation (FAR) 15.506 prohibits the release of the names of the individuals providing reference information about the Offeror’s past performance. Survey should be completed by the evaluator and returned to Robert Parke via email at robert.parke2@va.gov, no later than July 20th, 2018.

Please evaluate the Past Performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, provide additional information in the appropriate block or in the remarks section of this form.

O = Outstanding = Performance greatly exceeded contract requirements

A = Above Average = Performance exceeded contract requirements

S = Satisfactory = Performance met contract requirements

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

U = Unacceptable = Performance was poor and/or did not satisfy contract requirements

NOTE: Do not use a color marking pen to circle the response. Best to use a ball point pen (Black or Blue) to circle your response.

Describe exactly what types of patient assistance services or similar services were provided to your company/organization?

Length of the Service (Provide dates):

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

O A S M U

Q2. How timely was the contractor’s performance?

O A S M U

Q3. How well did the contractor comply with the labor and safety standards?

O A S M U

Q4. Rate the effectiveness of the contractor’s management of the contract?

O A S M U

Q5. Rate the contractor’s handling of staff integrity issues.

O A S M U

Q6. Rate the contractor’s personnel management practices.

O A S M U

Q7. Quality Control: Rate the overall quality of contractor’s work.

O A S M U

Q8. How well did the contractor comply with the training requirements with respect to its employees?

O A S M U

Q9. What extent was contractor flexible in responding to changing needs?

O A S M U

Q10. To what extent was the contractor reliable?

O A S M U

Q11. To what extent was the Contractor responsive to technical directions?

O A S M U

Q12. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, explain on the following page.

Yes No

Q13. Would you award another contract to this contractor? If no, explain on the following page.

Yes No

Q14. Was the customer satisfied with the service provided? If no, explain on the following page.

Yes No

Q15. To what extent did contractor notify you of problems of potential issues?

O A S M U

Past Performance Survey – Remarks Section

Evaluator’s Additional Remarks regarding services:

Signature of Evaluator: Date of Evaluation:

Print Name of Evaluator:

Please email scanned copy directly to Robert Parke at robert.parke2@va.gov Do NOT return survey to the company you are evaluating