ATTACHMENT 1 PAST PERFORMANCE QUESTIONAIRE.pdf

PAST PERFORMANCE QUESTIONNAIRE

Request for Quote - 36C24820Q0876

Perfusionist/Autotransfusion Services

1. Background: The Noprth Florida South Georgia VA Healthcare System (NFSGVAMC) has an ongoing requirement for Perfusionist/Autoperfusionist Services. The quoter has identified you as a reference to validate the their past performance. This questionnaire concerns past or current contracts/agreements for which you have personal knowledge.

2. Instructions: Please complete this questionnaire based on the following guidance.

Please take the time to answer the questions to the best of your knowledge. Circle the responses that best describe the company’s performance, and write in a narrative explanation for your answer. Use a N/A rating to indicate that you have no performance information for that particular area, or if the question does not apply to you. Each question has space for your comments. If more space is needed, please attach additional sheets to the end of the questionnaire and reference the respective question. Handwritten (ink) responses are sufficient.

Please complete the following questionnaire to assist our evaluation of the company’s past performance and return no later than 2:30 PM (EST) on closing date of solicitation to Cyrouse Himid Houshyani email at cyrouse.houshyani@va.gov.

Name of Company: __________________________

Title/Description of Proposed Project:

Please evaluate the past performance using only the following ratings without variation. If the rating is Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form.

“O” = Outstanding = Performance greatly exceeded the contract requirements

“A” = Above Average = Performance exceeded the contract requirements

“S” = Satisfactory = Performance met the contract requirements

“M” = Marginal = Performance met the minimum contract requirements but some material aspects of the company’s performance were less than satisfactory

“U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements

CUSTOMER SATISFACTION

mailto:brett.cook@va.gov

1. Company maintained a professional staff.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

2. Company was responsive to inquiries regarding contract/agreement.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

3. Company was flexible in responding to urgent requirements.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

4. Overall customer satisfaction.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

COMPLIANCE WITH STAFFING REQUIREMENTS

5. Company provided sufficient notice of personnel changes/additions, to ensure adequate time to credential personnel.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

6. Company consistently provided trained/qualified staff.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

7. Company ensured staff remained fully qualified/proficient at all times.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

Additional Comments

8. Was the company ever issued a cure or show cause notice under the referenced contract/agreement?

If yes, explain in “comments.” Yes / No

Comments:

9. Would you hire this company again?

If no, explain in “comments.” Yes No

BRIEF EXPLANATION OF RATING GIVEN:

Overall Rating: _________________________________

Name of Evaluator: ______________________ E-Mail: ___________________________________

Position Title /Grade:_____________________ Phone Number: ____________________________

Company/City: ________________________Date questionnaire completed: _________________

PAST PERFORMANCE QUESTIONNAIRE