Attachment 5 Past Performance Questionnaire.docx
DOCX document 21 KB Posted
- Attached to
- 6515--DTP-NG NATL CMOP RFP
- Solicitation number
- 36C77020R0003
About this file
This document is a past performance questionnaire template for a United States Department of Veterans Affairs solicitation for direct to patient distribution services. The solicitation number is 36C77020R0003 and is for the Consolidated Mail Outpatient Pharmacies facilities. The questionnaire is to be completed by both the contractor submitting the proposal and their listed references. The contractor will provide contact information and a description of previous work, and references will evaluate the contractor's past performance on a scale of one to five in categories such as staff qualifications, responsiveness, and quality control. References will also give an overall performance rating and may note any cure notices received. The questionnaire aims to assess the contractor's ability to successfully complete direct to patient distribution services for multiple VA medical facilities.
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Text version
PAST/PRESENT PERFORMANCE QUESTIONNAIRE
INSTRUCTIONS TO PRIME CONTRACTOR: (Contractor submitting proposal):
Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and submit it according to the instructions, below.
Company Name
Street Address
Point of Contact
City
Point of Contact Phone Number
State
E-Mail Address
Zip Code
| Solicitation Number |
| 36C77020R0003 |
| Description of Work |
| Direct to Patient Distribution Services for the Consolidated Mail Outpatient Pharmacies facilities |
INSTRUCTIONS TO REFERENCE CONTACT
The contractor named above is submitting a proposal for a United States Department of Veterans Affairs contract and has sent this form to you as a past performance reference contact. Please complete the following pages in full (all areas shaded in light yellow, below). Once completed, please return to vendor requesting the reference:
RESPONDENT INFORMATION [completed by Reference Contact]
Company Name (company rating contractor)
Street Address
POC Name
City
Phone Number
State
Fax Number
Zip Code
Contract Number performed
Period of Performance
Description of services provided
Location of services provided
Number of personnel provided
PERFORMANCE INFORMATION: Choose the number on the scale of 0 (Neutral) to 5 (Exceptional) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE AN EXPLANATION FOR THE OVERALL RATING in the Remarks section, below (text box will expand to whatever extent is necessary).
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| NEUTRAL |
| UNSATISFACTORY |
| MARGINAL |
| SATISFACTORY |
| GOOD |
| EXCEPTIONAL |
| No record of past performance or the record is incon-clusive. |
| Performance did not meet most contractual require-ments. There were serious problems and the contractor’s corrective actions were ineffective. |
| Performance did not meet some contractual requirements. There were problems, some of a serious nature, for which corrective action was only marginally effective. |
| Performance met most contractual requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory. |
| Performance met all contract requirements and exceeded some to the Government’s benefit. There were a few minor problems, which the contractor resolved in a timely, effective manner. |
| Performance exceeded all contract requirements. There were no problems. |
| The Contractor … |
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| 1. |
| Provided experienced managers and/or supervisors with the technical and administrative abilities needed to meet contract requirements. |
| |_| |
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| 2. |
| Demonstrated ability to hire, maintain, and replace, if necessary, sufficient qualified personnel throughout the contract period. |
| |_| |
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| 3. |
| Home office participated in solving significant local problems as necessary. |
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| 4. |
| Had sufficient personnel to monitor, support and provide oversight for large numbers of staff at geographically dispersed locations. |
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| 5. |
| Provided highly qualified personnel throughout the life of the contract. |
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| 6. |
| Corrected deficiencies in timely manner and pursuant to their quality control procedures. |
| |_| |
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| 7. |
| Provided timely resolution of contract discrepancies |
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| 8. |
| Identified problems as they occurred. |
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| 9. |
| Suggested alternative approaches to problems. |
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| 10. |
| Displayed initiative to solve problems. |
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| 11. |
| Managed on-boarding and background investigation process efficiently and timely. |
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| 12. |
| Was responsive to contract changes. |
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| 13. |
| Maintained consistent staffing levels for positions in cases of call outs, illnesses, injuries, etc. |
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| 14. |
| Cooperated with Company/Government personnel after award. |
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| 15. |
| Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.” |
| |_| |
| YES |
| |_| |
| NO |
| 16. |
| Would you award another contract to this contractor? If not, please explain in “remarks.” |
| |_| |
| YES |
| |_| |
| NO |
| 17. |
| OVERALL PERFORMANCE RATING: |
| |_| 0 |
| |_| 1 |
| |_| 2 |
| |_| 3 |
| |_| 4 |
| |_| 5 |
REMARKS (Please use as much space as is needed – the box will expand as you type).
I hereby certify that the information that I have reported above is accurate to the best of my knowledge.
Printed Name
E-mail address
Business Title
Signature
Date
File details come from the government source that posted it. Updated .