Attachment 4 - Past Performance Questionnaire_Final.docx

ATTACHMENT 4: PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for High Tech Medical Equipment (HTME) Acceptance Testing Services for the Department of Veterans Affairs’ National Acquisition Center (NAC), High-Tech Medical Equipment Ordering Division located in Hines, IL.

PAST PERFORMANCE INSTRUCTIONS

The National Acquisition Center (NAC) located in Hines, IL has issued a solicitation for inspection services on newly installed HTME systems at VA campuses nation-wide. These systems include, but are not limited to, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Single Photon Emission Computed Tomography (SPECT).

Past performance information will be used to evaluate RFP’s received. Section A is to be completed by the Offeror. Section A of the enclosed questionnaire lists the offeror who has identified your office/business as a source to evaluate their past performance. Section A also authorizes release of this information to the NAC.

The must provide this entire document to each of its assessors. The offeror shall only submit with its RFP (by the closing date of the Solicitation) copies of Section A of the questionnaire as provided to the assessors.

Section B, in its entirety, is to be completed by the assessor(s). An individual assessor knowledgeable of the contractor’s quality of services rendered is requested to verify dates and description of services rendered, complete the questionnaire, and submit to the Contracting Officer. If evaluating more than one contract for the same contractor, use a separate questionnaire for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing your assessment is greatly appreciated. The questionnaire should be completed as soon as possible but not later than April 20, 2025, 12:00 PM (Central). Assessor is requested to send electronically in PDF or Word format to leah.boyd2@va.gov.

Thank you in advance for your cooperation and expeditious response to this request.

PAST PERFORMANCE QUESTIONNAIRE

SECTION A: Offeror Information (to be completed by the offeror for whose past performance information is being collected, prior to forwarding to assessors)

1. Prospective Government Contractor’s

2. Name and Address:

3. Contractor Point of Contact:

4. Phone number (with area code):

5. Assessor Contract Award number:

6. Description of Services provided under contract:

7. Contract award date: Contract Amount: Initial Final

8. Period of Performance:

ASSESSOR INFORMATION:

Assessor Name

Title

Phone Number/Email Address

9. Authorization is hereby granted to provide the information requested in this questionnaire to the U.S. Department of Veterans Affairs’ National Acquisition Center.

(Signature)

(Name and Title of Authorizing Official) (Date)

SECTION B: Assessor’s Information (to be completed by assessors.)

RATING SCALE Definitions

Neutral / Not Applicable or Unknown (N)

No performance record identifiable within the area of evaluation.

The questions in the survey (see below) shall be rated in accordance with the definitions provided in the Rating Scale above. Please supplement any ratings other than “Satisfactory” with an explanation in the space provided.

1. QUALITY:

2. SCHEDULE/TIMELINESS OF PERFORMANCE:

Rate the contractor’s use of available resources to accomplish tasks identified in the contract

E

G

S

M

U

N

3. CUSTOMER SATISFACTION:

Contractor was reasonable and cooperative in dealing with your staff (including the ability to successfully resolve disagreements/disputes; responsiveness to administrative reports, businesslike and communication)

E

G

S

M

U

N

4. MANAGEMENT/ PERSONNEL/LABOR

5. COST/FINANCIAL MANAGEMENT

Have there been any indications that the contractor has had any financial problems? If yes, please explain below.

Yes

No

6. SAFETY/SECURITY

7. GENERAL

Would you hire or work with this firm again? (If no, please explain below)

Yes

No

Please provide straightforward responses to the questions above (if applicable) and/or additional remarks. Furthermore, please provide a brief narrative addressing specific strengths, weaknesses, deficiencies, or other comments which may assist our office in evaluating performance risk (attach additional pages if necessary):