Attachment 5 - Past Performance Questionnaire.pdf
PDF 375 KB Posted
- Attached to
- Q522--FY25: Teleradiology| Orlando
- Solicitation number
- 36C24825R0002
About this file
This is a Past Performance Questionnaire template for RFQ 36C24825R0002 for Teleradiology Services at the Orlando Veterans Affairs Medical Center (OVAMC). The questionnaire is designed to collect performance feedback from references identified by vendors bidding on the teleradiology services contract.
The questionnaire uses a five-tier rating system (Outstanding, Above Average, Satisfactory, Marginal, and Unacceptable) to evaluate vendors across four main areas: professional staff maintenance, responsiveness to contract inquiries, flexibility in handling urgent requirements, and overall customer satisfaction. References must provide written explanations for their ratings, particularly for any Marginal or Unacceptable scores. The form requires references to indicate if they would hire the company again and includes fields for the evaluator's contact information, position, and company details. Completed questionnaires are to be returned to Peter Bedard at peter.bedard@va.gov.
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Text version
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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