36C26318R0288-005.docx

Attachment 3

PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for Pierre, South Dakota Community Based Outpatient Clinic (CBOC).

FOR PROVIDERS OF PAST PERFORMANCE INFORMATION

Network Contracting Office 23, St Paul, Minnesota, has issued a solicitation to provide CBOC services in Pierre, SD.

Past performance information will be used to evaluate proposals 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 NCO23 St Paul, MN.

An individual knowledgeable of the contractor’s quality of supplies and 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 9/14/2018. Send by mail to NCO 23 Contracting, attention: Sandra McAnany, Warren E Burger Building, 316 Robert Street, Suite 506, St Paul, MN 55101 or electronically to sandra.mcanany@va.gov or fax the survey to 651-293-3032.

PAST PERFORMANCE SURVEY

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

1. Prospective Government Contractor’s______________________________________

2. Contractor Point of Contact: ___________________________________________

3. Phone number (with area code): __________________________________________

4. Contract number: ___________________________________________

5. Description of Supplies 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 NCO23, St Paul, MN.

(Signature)

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

(Typed or Printed Name) (Organization Name)

(Title)

Respondent should complete survey and submit No later than: 01/31/2015

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

E EXCEPTIONAL

Past performance has met contractual requirements and has exceeded many to the respondent's benefit. Contractual performance was accomplished with few minor problems for which corrective action(s) taken by the contractor were highly effective.

V VERY GOOD

Past performance has met contractual requirements and has exceeded some to the respondent's benefit. Contractual performance was accomplished with some minor problem(s) for which corrective action(s) taken by the contractor were effective.

S SATISFACTORY

Past performance has met contractual requirements. Contractual performance contains some minor problem(s) for which corrective action(s) taken by the contractor appear or where satisfactory.

M MARGINAL

Past performance has not met some contractual requirements. Contractual performance reflects a serious problem for which either the contractor has not yet identified correction action(s), or the proposed corrective action(s) appear only marginally effective or were not fully implemented.

U UNSATISFACTORY

Past performance has not met most contractual requirements, and recovery did not occur or was not in a timely manner. Contractual performance contains serious problem(s) for which the contractor's corrective action(s) appear or were ineffective.

N NEUTRAL

No performance record identifiable; unknown performance.

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

QUALITY OF SERVICE

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

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

COMMENTS:

SCHEDULE

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

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

BUSINESS RELATIONS

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

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

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

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

5. Overall rating of contractor’s business relations. E V S M 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.

Please return the completed, signed reference by fax or e-mail by 9/14/2018 to Sandra McAnany at FAX 651-293-3060 or e-mail sandra.mcanany@va.gov