Attachment 5 - Past Performance Questionnaire.pdf
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- Solicitation number
- 36C24826Q0063_2
About this file
This is a Past Performance Questionnaire for Request for Quote 36C24826Q0063 issued by the Bill Young Medical Center in Bay Pines. The questionnaire is designed to solicit references from past clients to evaluate a vendor's performance on Contracted Emergency Residential Services with a focus on Low Demand Safe Haven Services. Completed questionnaires must be returned to Peter Bedard at peter.bedard@va.gov by the date specified by the contractor.
The questionnaire uses a standardized five-point rating scale: Outstanding (O) for performance greatly exceeding requirements, Above Average (A) for performance exceeding requirements, Satisfactory (S) for performance meeting requirements, Marginal (M) for performance meeting minimum requirements with some deficiencies, and Unacceptable (U) for poor performance not satisfying requirements. Evaluators must rate four customer satisfaction criteria: company maintenance of professional staff, responsiveness to inquiries, flexibility in responding to urgent requirements, and overall customer satisfaction. Each rating requires a brief written explanation. Additional evaluation elements include a yes/no question on whether the evaluator would hire the company again with explanatory comments, and an overall rating field. The form requests evaluator contact information including name, email, position title/grade, phone number, company/city affiliation, and completion date. Handwritten responses in ink are acceptable.
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Attachment. D.5
PAST PERFORMANCE QUESTIONNAIRE
Request for Quote - 36C24826Q0063 Contracted Emergency
Residential Services with a focus on Low Demand Safe Haven
Services.
1. Background: The Bill Young Medical Center in Bay Pines has an ongoing requirement for Contracted Emergency Residential Services with a focus on Low Demand Safe Haven 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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