36C26119Q0007-004.docx

Attachment 4 PAST PERFORMANCE QUESTIONNAIRE

SUBJ: Past Performance Questionnaire for VA Southern Nevada Healthcare System (VASNHS) Emergency Room Physician services.

FOR PROVIDERS OF PAST PERFORMANCE INFORMATION

Network Contracting Office 21, Las Vegas, has issued a solicitation to provide Emergency Department Physician Services for the Veterans Affairs Southern Nevada Healthcare System (VASNHS).

Past performance information will be used to evaluate quotes received. Section A of the enclosed survey lists the contractor who has identified your office as a source to evaluate their past performance. Section A also authorizes release of this information to NCO 21, Las Vegas.

An individual knowledgeable of the contractor’s quality of services rendered should complete the survey, providing comments wherever applicable. However, supplemental information from others in your organization is encouraged. If evaluating more than one contract for the same contractor, use a separate survey for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing it is greatly appreciated. The survey should be completed as soon as possible but not later than 2/22/2019. Send electronically to tracy.worrell@va.gov.

Attachment 4 – Past Performance Questionnaire 36C26119Q0007

PAST PERFORMANCE QUESTIONNAIRE

SECTION A: Contractor Information (to be completed by the contractor for who past performance information is being collected, prior to forwarding to respondent)

2. Contractor Point of Contact: _______________________

3. Phone number (with area code): ____________________

4. Contract number: ________________________________

5. Description of Services provided under contract referenced in item 4: ________________________________________________________________________

6. Contract award date: Contract award amount: _________________

7. Period of Performance or Delivery Date: ________________________________________

8. Authorization is hereby granted to provide the information requested in this survey to NCO 21.

(Signature)

(Name and Title of Authorizing Official)

SECTION B: Respondent Information (to be completed by respondent)

(Signature) (Typed or Printed Name) (Organization Name)

Please summarize contractor’s performance and circle the letter on the right which best corresponds to the performance rating for each question. Please follow the rating guidelines below for description of rating scale:

The following Rating Scale provides the definitions for the Past Performance ratings to be assessed:

The questions on the survey shall be rated in accordance with the definitions provided in the Rating Scale. Any unsatisfactory rating shall be supplemented with an explanation in the space provided.

QUALITY OF SERVICE

1. Rate the contractor’s compliance with contractual E G S U N requirements.

2. Overall rating of contractor quality of service. E G S U N

COMMENTS:

SCHEDULE

1. Delivery of service was within required time E G S U N period specified by contract requirements.

2. Overall rating of contractor conformance to E G S U N schedule.

BUSINESS RELATIONS

1. Rate the working relationship between contractor’s E G S U N management, your company and your designated representatives (to include inspection personnel).

2. Rate the contractor’s ability to submit reports E G S U N and/or invoices. Are they complete and accurate?

3. Rate the contractor's ability to submit required E G S U N reports and/or invoices in a timely manner.

4. Rate the contractors responsiveness to customer E G S U N complaint resolution.

5. Overall rating of contractor’s business relations. E G S U N

COMMENTS

How would you feel about awarding another contract to this contractor?

______ Would not hesitate to award another contract to this contractor.

______ Would most likely award another contract to this contractor.

______ Would think twice about awarding another contract to this contractor, but would do so if no better alternative existed.

______ Do not wish to award another contract to this contractor.

______ Would not award another contract to this contractor.

Signature: Date: