Atch7_36C25522Q0099_CSS_PastPerfQuest(PPQ).pdf

Combined Synopsis-Solicitation for Commercial Items Request for Quotation (RFQ) 36C25522Q0099

PAST PERFORMANCE QUESTIONNAIRE: Solicitation 36C25522Q0099

Attachment 7 SUBJECT: Past Performance questionnaire for Sleep Study Services, Robert J. Dole VA Medical Center.

FOR PROVIDERS OF PAST PERFORMANCE INFORMATION

NCO 15 Contracting Officer, Healthcare Branch, Leavenworth, Kansas has issued a solicitation for the procurement of Sleep Study Services, on-site at the VAMC (aka Polysomnography Services), including contractor scheduling of VA patients for this service (on-site), patient management and monitoring, study-type determination, adjustment/change where necessary, scoring and documenting the study and result. Service to include up to 2 patients per study night (some days). Service to include scoring of home sleep studies performed with VA-owned equipment returned to the VA for scoring by sleep study contractor.

Past performance information will be used to evaluate proposals received. The past performance questionnaire lists the contractor who has identified your office as a source of past performance, within the previous 3 years, to evaluate their past performance. Completion of the past performance questionnaire, and providing it also authorizes release of this information to the requesting Contracting Officer.

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, please 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.

Summary of the solicitation: Services 7 days per week, 365 days per year including holidays and weekends, 8:00pm to 8:00am daily, and periodically as required 8:am to 5:30pm for daytime services.

Annual services estimates include 600 home sleep study scoring required, (CPT code used is 95800), estimating 10 95805, 150 95808, 100 95810 and 75 95811. VA estimates about 10% incomplete (unable to be scored). All space, equipment, consumables, programs are Government-owned. Contractor shall supply Registered Polysomnographic Technicians to perform the services. All services are performed on-site. Off-site work does not apply. Interpretation does not apply. Diagnosis does not apply.

Completed Questionnaires should be emailed directly to Contracting Officer Michael Cumins, michael.cumins@va.gov no later than 10/24/2022, 10:00 a.m. Central Time. Any questions may be directed to the Contracting Officer using e-mail, or by calling (913) 946-1122 if there are questions with this form or content.

Note: Completed questionnaires should be submitted directly by the company and individual completing the past performance questionnaire.

Offeror’s Name (Contractor that provided Services)(the offeror will fill-in before sending to reference point of contact):

Name of Person Providing Reference:

mailto:michael.cumins@va.gov

Telephone: _____________________________ E-Mail: ______________________________________

Title_____________________________ Company/Organization: _______________________________

Location of Services Provided (City, State, and Zip code): _____________________________________

Please rate the Offeror in each of the following areas. Note there is room for comments (add more where needed); please provide comments supporting your rating. Circle/mark your response on each question.

Rating Definition Excellent (E)

Based on the offeror’s performance record, essentially no doubt exists that the offeror will successfully perform the required effort. Past/present performance effort involved essentially the same magnitude of effort and complexities this solicitation requires

Good (G) Based on the offeror’s performance record, little doubt exists that the offeror will successfully perform the required effort. Past/present performance effort involved much of the magnitude effort and complexities this solicitation requires Satisfactory (S) Based on the offeror’s performance record, some doubt exists that the offeror will successfully perform the required effort. Past/present performance effort involved some of the magnitude of effort and complexities this solicitation requires Neutral/Unknown (N) No relevant performance record is identifiable (see FAR 15.305(a)(2)(iii) and (iv)) Marginal (M) Based on the offeror’s performance record, substantial doubt exists that the offeror will successfully perform the required effort. Past/present performance effort involved very little of the magnitude of effort and complexities this solicitation requires.

Unsatisfactory (U) Based on the offeror’s performance record, extreme doubt exists that the offeror will successfully perform the required effort. Past/present performance effort did not involve any of the magnitude of effort and complexities this solicitation required.

1. Quality of Performance

a. Compliance with contract or agreement requirements/terms? E G S N M U

b. Use of appropriate staff? E G S N M U

c. Technical capabilities and performance? E G S N M

Comments:

2. Timeliness of Performance

a. Timely advance patient scheduling for studies/rescheduling? E G S N M U

b. Ability to meet schedule for score due dates/times? E G S N M U

c. Responsive to technical direction and complaint resolution? E G S N M

3. Report Submission E G S N M U

a. Timely scoring reporting and documenting in patient records? E G S N M

4. Customer Satisfaction E G S N M

a. Committed to customer & patient satisfaction? E G S N M U

b. Cooperative, reasonable business like behavior? E G S N M U

c. Effective management, responsiveness to contract requirements? E G S N M U

d. Honesty and integrity, prompt notification of problems, flexible and proactive qualities and effective staff and management?

E G S N M U

5. Training Requirements

a. Willingness to complete any mandatory training? E G S N M

6. Invoice Timeliness and Accuracy

a. Were invoices submitted timely? E G S N M

b. Were they accurate? Or corrected timely? E G S N M

7. Based on the firm’s overall performance, would you award them another contract or agreement for services, including continuation of a current contract or agreement?

[ ] YES [ ] NO If no, please explain:

8. Have you issued or expressed any notifications or letters of concern, cure notice, show cause notice, suspension of payments or other letters directing the correction of a performance problem in the past 3 years?

[ ] YES [ ] NO If yes, please explain:

9. Have you terminated this firm for default within the past 3 years, or are there any pending termination actions?

[ ] YES [ ] NO If yes, please explain:

10. Have you discussed any adverse past performance problems with the firm, and given them an opportunity to comment or correct?

[ ] YES [ ] NO If Yes, please provide details and explain:

11. Have you filed past performance information in a database that the Contracting Officer may search?

[ ] YES [ ] NO If Yes, please provide the name of the database:

12. Did the firm take care of your equipment or supplies in performance of the work they performed? [ ] YES [ ] NO If No, please provide details and explain:

13. Would you recommend the firm to perform the work we require? [ ] YES [ ] NO If No, please provide details and explain: