Attachment 5 - Past Performance Questionnaire.pdf
PDF 375 KB Posted
- Solicitation number
- 36C24826R0062
About this file
This is a Past Performance Questionnaire for Request for Quote 36C24825R0002 issued by the Orlando Veterans Affairs Medical Center (OVAMC) for Off-Site Teleradiology Services. The questionnaire is distributed to past or current customers of a vendor being evaluated as a reference to assess the contractor's performance history. Completed questionnaires must be returned to Peter Bedard at peter.bedard@va.gov by a date specified by the contractor.
The questionnaire evaluates vendor performance across customer satisfaction dimensions using a five-point rating scale: Outstanding (O), Above Average (A), Satisfactory (S), Marginal (M), and Unacceptable (U). Evaluators must rate the company on four specific criteria: maintenance of professional staff, responsiveness to contract inquiries, flexibility in responding to urgent requirements, and overall customer satisfaction. Additional evaluation areas include whether the reference would hire the company again. Respondents are required to provide narrative explanations for any Marginal or Unsatisfactory ratings. The questionnaire requests evaluator information including name, email, position title/grade, phone number, company/city, and completion date. Handwritten responses in ink are acceptable, and additional sheets may be attached if more space is needed for comments.
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Attachment. D.5
PAST PERFORMANCE QUESTIONNAIRE
Request for Quote - 36C24825R0002
Teleradiology Services
1. Background: The Orlando Veterans Affairs Medical Center (OVAMC) has an ongoing requirement for Off-Site Teleradiology Services. The vendor has identified you as a reference to validate the their past performance. This question is concerns pass or current contractors/agreements for which you have personal knowledge.
2. Instruction: 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 you answer. Use a N/A rating to indicate that you have no performance 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 to respective questions. 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 the contractor advises. Please return to Peter Bedard email at peter.bedard@va.gov .
Name of Company: _____________________________________________
Title/Description of Proposed Project:
Please evaluate the past performance using only the following ratings without variation. If the ratings is Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form
“O” = 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 meet 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 mailto:osetta.quinn@va.gov
CUSTOMER SATISFACTION
1. Company maintain a professional staff.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
2. Company was responsive to inquiries regarding contract/agreement.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
3. Company was flexible in responding to urgent requirements.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
4. Overall customer satisfaction.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
Outstanding Above Average Satisfactory Marginal Unacceptable
5. Would you hire this company again?
If yes, explain in “comments.” Yes/No
Comments:
Overall Rating: ____________________________________
Name of Evaluator: ______________________________ E-Mail: ______________________________
Position Title/Grade: _____________________________ Phone Number: _______________________
Company/City: _____________________ Date Questionnaire Completed: ______________________
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