ATTACHMENT 5 - PAST PERFORMANCE QUESTIONNAIRE.pdf

ATTACHMENT 5 – PAST PERFORMANCE QUESTIONNAIRE

PAST PERFORMANCE QUESTIONNAIRE

36C24923Q0326

REFERENCE INSTRUCTIONS: The Network Contracting Office 9 is soliciting for award of a VA contract for Emergency Medicine Services. Your comments would be appreciated regarding this firm’s past performance.

The intent of this form is to evaluate contractors who have provided Licensed Pharmacist and Certified Pharmacy Technician Services in the past.

Survey must be completed by evaluator and sent to Christina Witt via email at christina.witt@va.gov.

Information of Company to be Evaluated Company name: ________________________________ Address: ________________________________ Phone: ________________________________ Email: ________________________________

Information of Evaluating Agency Evaluator’s name: ________________________________ Title: ________________________________ Agency name: ________________________________

Information regarding your Contract with the company to be evaluated:

Estimated Contract Amount: ________________________________ Contract Period of Performance: ________________________________ Type of Services rendered: ________________________________

Please evaluate the past performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, 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 met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory “U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements

Please rate and provide information/comments for the following: Circle one Q1. To what extent did the contractor comply with contract requirements?

O A S M U

Q2. If reports were required, were they accurate in meeting contract requirements?

Q3. To what extent did the contractor use appropriate personnel for contract requirements?

mailto:christina.witt@va.gov

Please rate and provide information/comments for the following: Circle one Q4. To what extent was contractor able to meet the performance schedule:

Q5. What extent was contractor flexible in responding to changing needs?

Q6. To what extent was the contractor reliable?

Q7. To what extent was the contractor responsive to technical directions?

Q8. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, please explain.

Yes No

Q9. Would you award another contract to the party being evaluated? If no, please explain:

Yes No

Q10. To what extent did contractor notify you of problems or potential problems?

11. Please describe services provided under your contract, period of performance and total cost:

12. Additional Remarks:

Signature of Evaluator

Date