ATTACHMENT 1 PAST PERFORMANCE QUESTIONAIRE.pdf

Attachment D.1 RFQ 36C24822Q1383

PAST PERFORMANCE QUESTIONNAIRE

Request for Proposal- 36C24822Q1383

Chief/Theraputic Medical Physicist Services

1. Background: The Bay Pines VA Healthcare System (BPVAHCS) has an ongoing requirement for

Chief/Therapeutic Medical Physicist Services. The vendor 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 perform ance 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 the date that the contractor advises. Please return to Cyrouse Himid Houshyani email at cyrouse.houshyani@va.gov.

Name of Company: ___________ _

Title/Description of Proposed Project that assessor is filling past performance information on (I.E. what type of work was accomplished by the Contractor):

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.

"0" = 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

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