Attachment 4- Past Performance.pdf

36C26320R0025

PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for Nephrology Services- VA Black Hills

REQUEST FOR PAST PERFORMANCE INFORMATION

Network Contracting Office 23 of the Department of Veterans Affairs has issued a solicitation for medical services. The Black Hills VAMC has a requirement for nephrology needs. This includes weekday after-hours on-call, weekend/holiday on-call, and inpatient after-hours consultation. Additionally, this requirement includes monthly dialysis rounds.

Past performance information will be used to evaluate quotes received. Section A of the enclosed survey lists the contractor (offeror) who has identified your office as a source to evaluate their past performance. Section A also authorizes release of this information to NCO23 St. Paul, MN.

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, 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 but not later than the solicitation due date. Send electronically to matthew.dale3@va.gov.

Attachment 4

VHAMINBaumaK Typewritten Text

Please forward to reference company/agency to complete Section B.

PAST PERFORMANCE QUESTIONNAIRE

SECTION A: Contractor Information (to be completed by the offeror, prior to forwarding to respondent)

Prospective Government Contractor’s Name and Address:

Contractor Point of Contact: ___________________________________________

Phone number: ___________________________________________

Description of Services provided to Respondent:

Service dates: _________________ Contract award amount: _______________

Authorization is hereby granted to provide the information requested in this survey to NCO23, Minneapolis, MN.

(Signature) (Date)

(Printed Name and Title of Authorizing Official)

SECTION B: Respondent Information (to be completed by respondent)

Respondent Company/Organization Name and Address:

Respondent Point of Contact: ___________________________________________

Phone number: ___________________________________________

The following scale provides the definitions for the Past Performance ratings to be assessed:

Exceptional

Based on the Offeror's performance record, essentially no doubt exists the Offeror will successfully perform the required effort. Past performance has met contractual requirements and has exceeded some to the respondent's benefit. Contractual performance was accomplished with few minor problems for which corrective action(s) taken by the contractor were highly effective.

Very Good

Based on the Offeror's performance record, little doubt exists the Offeror will successfully perform the required effort. Past performance has met contractual requirements and has exceeded some to the respondent's benefit.

Contractual performance was accomplished with some minor problem(s) for which corrective action(s) taken by the contractor were effective.

Satisfactory

Based on the Offeror's performance record, some doubt exists the Offeror will successfully perform the required effort. Past performance has met contractual requirements. Contractual performance contains some minor problem(s) for which corrective action(s) taken by the contractor appear or were satisfactory.

Marginal

Based on Offeror's performance record, substantial doubt exists the Offeror will successfully perform the required effort. Past performance has not met some contractual requirements. Contractual performance reflects a serious problem for which either the contractor has not yet identified correction action(s), or the proposed corrective action(s) appear marginally effective.

Unsatisfactory

Based on Offeror's performance record, extreme doubt exists the Offeror will successfully perform the required effort. Past performance has not met most contractual requirements, and recovery did not occur or was not in a timely manner. Contractual performance contains serious problem(s) for which the contractor's corrective action(s) were ineffective.

Neutral No performance record identifiable; unknown performance.

Using the ratings scale, please complete the questionnaire. Use the drop down menus to provide answers. Supplement your answers with explanations in the comment space provided.

QUALITY OF SERVICE

1. Rate the contractor’s compliance with contractual requirements:

2. Overall rating of contractor quality of service:

COMMENTS:

SCHEDULE

1. Requirements were completed within required time period:

2. Overall rating of contractor ability to complete schedule:

COMMENTS:

Please return the completed questionnaire to Matthew Dale at Matthew.Dale3@va.gov

BUSINESS RELATIONS

1. Rate the working relationship between contractor’s management, your company, and other representatives (to include inspection personnel).

2. Rate the contractor’s ability to submit complete and accurate reports and/or invoices.

3. Rate the contractor's ability to submit required reports and/or invoices in a timely manner.

4. Rate the contractor’s responsiveness to customer complaint resolution.

5. Overall rating of contractor’s business relations.

COMMENTS:

How would you feel about awarding another contract to this contractor? (choose one)

__ Would not hesitate to award another contract to this contractor.

__ Would most likely award another contract to this contractor.

__ Would think twice about awarding another contract to this contractor, but would do so if no better alternative existed.

__ Do not wish to award another contract to this contractor.

__ Would not award another contract to this contractor.

COMMENTS:

(Signature) (Date)

(Printed Name and Title)