ATTACHMENT D.3 PAST PERFORMANCE QUESTIONNAIRE.pdf

PAST PERFORMANCE QUESTIONNAIRE FOR __________________________________________

(COMPANY NAME (QUOTER) FOR WHICH QUESTIONNAIRE IS

BEING COMPLETED)

Request for Quote - - Cancer Registrar (CTR) Services

1. Background: The VA Network Contracting Office (NCO) – 10 and the Battle Creek VA Medical Center is conducting a competitive acquisition for Cancer Registrar Services. The quoter has identified you as a reference to validate the quoter’s past performance. This questionnaire concerns past or current contracts/ agreements for which you have personal knowledge of quoter's performance.

2. Instructions: 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 your 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 the respective question. 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 2:00 PM (EST) on to Sally L. Leitch via email at Sally.Leitch@va.gov.

Name of Company completing questionnaire: __________________________

Title/Description of Project for which services were performed:

Please evaluate the past performance using only the following ratings without variation. If the rating 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 met 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

CUSTOMER SATISFACTION

mailto:brett.cook@va.gov

1. Company maintained a professional Cancer Registrar 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 any urgent requirements or changes to scope of work.

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:

COMPLIANCE WITH STAFFING REQUIREMENTS

5. Company provided sufficient notice of personnel changes/additions, to ensure adequate time to credential personnel.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

6. Company consistently provided trained/qualified tumor registry staff.

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

7. Company ensured tumor registry staff remained fully qualified/proficient at all times based on standards by National Cancer Registrars Association (NCRA) and the Commission on Cancer (COC).

Outstanding Above Average Satisfactory Marginal Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

Additional Comments

8. Were services performed at your facility or virtual at quoter's location? (place "X" where applicable)

At my location: ______ Virtual: _____

9. Was quoter familiarized with the use of your company's computer software in performing tumor registry abstracting services?

If yes, explain in "comments." Yes /No and briefly explain computer software used.

Comments: _____________________________________________________________________

10. Was the company ever issued a cure or show cause notice under the referenced contract/agreement?

If yes, explain in “comments.” Yes / No

Comments:

9. Would you hire this company again to perform tumor registry abstracting services?

If no, explain in “comments.” Yes No

BRIEF EXPLANATION OF RATING GIVEN:

Overall Rating: _________________________________

Name of Assessor: ______________________ e-Mail: ___________________________________

Position Title /Grade:__________________________ Phone Number: _________________

Company Name: ________________________ Address: ___________________________________

Note: Assessor shall not be an employee of company submitting quote. Submit Past Performance

Quesionnaire directly to Sally.Leitch@va.gov.

Date questionnaire completed: _________________

NOTE: Upon completion of questionnaire, please email directly to Raimundo Rivera at raimundo.rivera@va.gov and Cyrouse H. Housyhani at cyrouse.housyhani@va.gov. Thank you.

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PAST PERFORMANCE QUESTIONNAIRE