36C77620R0002-048.docx

Attachment K

PAST PERFORMANCE QUESTIONNAIRE

The Department of Veterans Affairs, Veterans Health Administration - Program Contracting Activity – Central (PCAC) is considering the Offeror listed below for award of a contract to provide a Tele-ICU solution for Veterans Health Administration.

Your comments would be appreciated regarding this firm’s past performance. The intent of this form is to evaluate the company’s ability to perform the work as described in the solicitation. Please complete the enclosed questionnaire as thoroughly as possible. Space is provided for comments. In addition to submitting this questionnaire, the PCAC may contact you in order to obtain any additional information regarding a contract award.

Please email your completed questionnaire to Adeitra.Jimmison@va.gov and Clayton.Smith2@va.gov no later than the date proposals are due.

**All Email Correspondence for this project must reference the RFQ Number, Project Identifier and Project Title in the subject line of the email:36C77620R0002, Tele-ICU

If you have questions regarding the attached questionnaire, or require assistance, please email Adeitra Jimmison and Clayton Smith at Adeitra.Jimmison@va.gov and Clayton.Smith2@va.gov.

Past Performance Information:

Name and Address of Company (Offeror) being evaluated:

Contract Number/Delivery or Task Order Number, Title, & Location of project the Offeror performed:

Evaluator: (The following information will assist in the analysis of the data. Information will be kept confidential)

Name of Evaluator:

Address:

Phone Number:

Position held or function in relation to project:

Rating: Please evaluate the past performance using only the following ratings without variation. DO NOT RATE ON A “+” OR “-“ SCALE. If a “+” or “-“ is used, the rating without the "+" or "-" will be applied. In addition to the ratings, please provide a short narrative in the appropriate block or in the remarks section of this form.

Please rate and provide any supporting information/comments for the following:

1. The quality of the working relationship with the client (the tenant and/ or owner).

O A S U

2. The professionalism and integrity with which offeror conducted business.

O A S U

3. The responsiveness to the client’s needs and expectations.

O A S U

4. The Offeror’s ability to manage and perform the project successfully.

O A S U

5. The offeror’s level of communication.

O A S U

6. The quality control of the project.

O A S U

7. Would you award another contact to the party being evaluated? If no, please explain.

Yes No

8. The delivery of the project was on schedule.

O A S U

9. Overall rating for this firm:

O A S U

Signature of Evaluator

Date