D.2 PAST PERFORMANCE QUESTIONNAIRE 05 30 23.docx
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- Attached to
- Q522--41 FTE Radiology Service Technologists (DRT & MIT) for VAPAHCS Satellite and CBOCs (RFP AMENDMENT #3)
- Solicitation number
- 36C26123R0027
About this file
This document contains a past performance questionnaire template for evaluating offerors on federal contracts for temporary medical staffing services. The past performance questionnaire requests evaluators to rate offerors on up to 17 performance criteria using ratings of outstanding, above average, satisfactory, marginal, and unacceptable. Evaluators are asked to provide comments on any ratings of marginal or unacceptable. The questionnaire also requests yes or no responses to questions on cure notices, willingness to award future contracts, customer satisfaction, and invoice and request responsiveness. Evaluators are asked to provide additional remarks and signature before returning the completed questionnaire by June 15, 2023 to an email address provided.
The related federal contract opportunity is a solicitation for 41 full-time equivalent radiology service technologists across a Veterans Affairs medical center and its community-based outpatient clinics. The solicitation is a single-award indefinite-delivery/indefinite-quantity contract issued by the Veterans Health Administration under Veterans Integrated Service Network 21 and the Department of Veterans Affairs.
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Past Performance Information
OFFEROR INSTRUCTIONS: A separate record must be completed for each Past Performance Information and Survey; Offeror must directly send to the evaluator, requesting they complete and return as indicated on the attached Past Performance Survey, no later than, June 15, 2023 to larry.facio@va.gov. Offeror must include a copy of each requested Past Performance Information page with proposal submission.
Name of Offeror being evaluated:
Address of Offeror:
Contract Details (i.e. Contract #/ Delivery or Task Order #, Title, Location, etc.)
Evaluator’s Full Name:
Evaluator’s Position held or function in relation to project:
Evaluator’s Company/Organization Name, Address and Phone number:
Evaluator’s email address:
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 larry.facio@va.gov, no later than the above date.
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 type of temporary staffing or similar service(s) were provided to your company/organization?
Length of the Service (Provide dates):
| Rate the following questions if the company provided temporary medical staffing or similar services. Provide information/comments in the Remarks Section below. |
| Circle One |
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 |
| Q16. Did the Contractor submit accurate invoices during the performance period? |
| Yes No |
| Q17. Was the contractor professional and courteous in its interaction with you? |
| Yes No |
Q18. Did the contractor respond promptly to requests?
Yes No
Q19. Did the contractor meet all expectations under the contract?
Yes No
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 larry.facio@va.gov Do NOT return survey to the company you are evaluating
File details come from the government source that posted it. Updated .