ATTACHMENT D.4 - PAST PERFORMANCE QUESTIONNAIRE.docx
DOCX document 21 KB Posted
- Solicitation number
- 36C24924R0034
About this file
This document is a Past Performance Questionnaire that is part of a Request for Proposal (RFP) for a Department of Veterans Affairs contract to provide Emergency Room Physician services. The intent of the questionnaire is to evaluate the past performance of contractors who have provided emergency medicine services. The questionnaire asks the evaluator to rate the contractor's performance across various criteria including contract compliance, reporting accuracy, use of appropriate personnel, meeting performance schedules, flexibility, reliability, responsiveness, and notification of problems. The evaluator is also asked whether they would award another contract to the contractor and to provide additional details about the prior contract, including the services provided, period of performance, and total cost. This questionnaire is specific to RFP 36C24924R0034 for the VA's Emergency Room Physician services contract with a period of performance from 10/01/2024 to 09/30/2029.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24924R0034 0001.docx | DOCX document | |
| ATTACHMENT D.1 - QUALITY ASSURANCE SURVEILLANCE PLAN.docx | DOCX document | |
| ATTACHMENT D.3 - CONTRACTOR CERTIFICATION.docx | DOCX document | |
| ATTACHMENT D.5 - ORG CONFLICT OF INTEREST.docx | DOCX document | |
| ATTACHMENT D.2 - RULES OF BEHAVIOR.docx | DOCX document | |
| 36C24924R0034.docx | DOCX document |
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Text version
Attachment D.4 – Past Performance Questionnaire
RFP 36C24924R0034
PAST PERFORMANCE QUESTIONNAIRE
REFERENCE INSTRUCTIONS: The Network Contracting Office 9 is soliciting for award of a VA contract for Emergency Room Physician services. Your comments would be appreciated regarding this firm’s past performance. The intent of this form is to evaluate contractors who have provided Emergency Medicine Services in the past.
Survey must be completed by evaluator and sent to the contracting specialist, Laura Edelman via email at laura.edelman@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?
O A S M U
Q3. To what extent did the contractor use appropriate personnel for contract requirements?
O A S M U
| Please rate and provide information/comments for the following: |
| Circle one |
Q4. To what extent was contractor able to meet the performance schedule:
O A S M U
Q5. What extent was contractor flexible in responding to changing needs?
O A S M U
Q6. To what extent was the contractor reliable?
O A S M U
Q7. To what extent was the contractor responsive to technical directions?
O A S M U
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?
O A S M U
11. Please describe services provided under your contract, period of performance and total cost:
12. Additional Remarks:
Signature of Evaluator
Date
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