Attachment 2 - Past Performance Survey.docx
DOCX document 23 KB Posted
- Solicitation number
- 36C24921Q0195
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PAST PERFORMANCE SURVEY
MOBILE LITHOTRIPSY LASER EQUIPMENT AND SERVICES
REFERENCE INSTRUCTIONS: The Department of Veterans Affairs is seeking offerors for award of a VA contract for Mobile Lithotripsy Laser Equipment and Services for the James H. Quillen VA Medical Center. You have been identified as a reference and your comments would be appreciated. Your comments are considered Source Selection Sensitive; therefore, you are advised that the release of the names of individuals providing reference information about Offeror’s past performance is prohibited. Survey should be completed by evaluator and submitted no later than March 31, 2021 @ 3:00PM CT via email directly to dewana.raynor@va.gov.
NOTE: Incomplete or unsigned surveys will not be considered.
Company being evaluated: _______________________________________________ Period of Performance:
What was the average monthly volume of the services provided? (Average number of hours worked per month?) ______________________________________ Name and title/position of evaluator:
Contact telephone number:
Contact e-mail address:
Please evaluate the past performance using only the following ratings without variation. If the rating is other than Fully Acceptable, please provide additional information in the appropriate block or in the remarks section of this form.
S = Superior Performance
V = Very Good with very few issues
F = Fully Acceptable/Good
M = Marginally Acceptable
U = Unacceptable Performance
| Please rate and provide information/comments for the following: |
| Circle/indicate selection |
| Q1. Rate how well the contractor complies with requirements and/or expectations? |
| S V F M U |
| Q2. Rate contractor’s knowledge and expertise in providing mobile lithotripsy services. |
| S V F M U |
| Q3. Rate this contractor’s medical laser safety officers. |
| S V F M U |
| Q4. Rate the level of access to the contractor’s personnel. (i.e. Did they respond in a timely manner? Did they meet the requirements of being available and responding as according to the contract?) |
| S V F M U |
| Q5. Rate overall ease of contractor’s scheduling process. |
| S V F M U |
| Q6. Rate how well contractor protects the privacy of patients. |
| S V F M U |
Q7. Would you award another contract to the firm being evaluated? If no, please explain:
Yes No
Additional Remarks: Please use this space to indicate anything else you would like to say about the contractor being referenced or to list anything you especially liked or disliked about this contractor:
| Signature of Evaluator |
| Date |
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