Attachment 5 Past Performance Questionnaire .rtf

ATTACHMENT FIVE

PAST PERFORMANCE QUESTIONNAIRE

Solicitation: 36C24823Q1690 – Radiation Oncology Therapy Services Department of Veterans Affairs (VA) Bruce W. Carter VA Medical Center (VAMC) Miami VA Healthcare System (MVAHCS) Network Contracting Office - 8

Message to the assessor: Your assistance is requested by Raimundo Rivera, the VA Contract Specialist to assist with establishing the performance history for the Company (Offeror) named below for which this Past Performance Questionnaire is being completed. In efforts to expedite receipt of the requested information, the Contracting Office respectfully requests that you do not mail hard copies. Instead, please e-mail the completed past performance questionnaire to Raimundo.rivera@va.gov. If not enough space is provided, please attach additional information/pages to this questionnaire. Please return the past performance questionnaire on or before the closing date of the solicitation 8/14/2023.

Name of Offeror: Contract #

Title/Description of Services: _____________________________ Location of contract performance: _________

Based upon the definitions below, indicate your assessment of the offeror’s performance. Your assessment should consider the offeror’s performance in accordance with the contractual requirements. Please include the period of performance (POP) and contract value:

POP: ___________________________________ Contract value ($): _________________________

Brief description of scope of work performed by Company (Offeror): ________________________________

EVALUATION: Please rate the offeror using the guide below. Explanatory narratives for as many responses as possible would be appreciated. These narratives need not be lengthy, just detailed. Attach additional pages if more space is needed. Rate by placing an (X) in the appropriate rating box.

Assessment Definition The Offeror’s performance met contractual requirements and exceeded many requirements to the Client’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the offeror were Outstanding (O)

Above Average (A) The Offeror’s performance met contractual requirements and exceeded some requirements to the Client’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the offeror were effective.

Satisfactory (S) The Offeror’s performance met contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the offeror were satisfactory.

Unacceptable (U) Performance did not meet contractual requirements. The contractual performance reflected a serious problem for which the offeror has yet to identify corrective actions or the offeror’s proposed actions appear only marginally effective or were not fully implemented.

Completed scheduled services in a timely manner per the Performance Work Statement (PWS).

O A S U Compliance with contractual Terms and Conditions.

O A S U Demonstrated ability to hire, maintain, and replace, if necessary, qualified key personnel during the contract period.

O A S U Provided effective quality control and/or inspection procedures to meet contract requirements.

O A S U Corrected deficiencies in timely manner and pursuant to the offeror’s quality control procedures.

O A S U Exhibited knowledge of and compliance with Government (or other) regulations and industry standards.

O A S U How effective was the offeror in responding to urgent requests in a timely manner per the Performance Work Statement (PWS)?

O A S U To what extent was the offeror able to solve contract performance problems without extensive guidance from procurement or technical staff.

O A S U Provides timely and accurate documents, records, and invoices as required by the contract.

O A S U Would you award similar contracts to this offeror? Please provide explanation for your response in the additional comments section.

YES

NO

Rate the Offeror’s OVERALL quality of performance under the contract performed.

O A S U

EXPLANATION OF OVERALL QUALITY OF PERFORMANCE RATING GIVEN:

ADDITIONAL COMMENTS (as required): ________________________________________________

Name of Assessor: ______________________________ Signature: _____________________________

Company/Agency: Date:

Position Title/Grade: Phone:

Email: