Attachment D.4 - Past Performance Survey-Questionnaire.docx
DOCX document 29 KB Posted
- Solicitation number
- 36C24926Q0140
About this file
This is a Past Performance Survey Questionnaire template designed to evaluate contractor performance on outpatient clinic services and temporary medical staffing contracts. The survey must be completed by an independent evaluator (not the offeror) and submitted directly to Ramona Bonness at ramona.bonness@va.gov by March 18, 2026 at 11:00 AM CT. The evaluation applies to the James H. Quillen VA Medical Center's requirement for Board Certified Anesthesiology Physician services under solicitation 36C24926Q0140.
The survey uses a five-point rating scale (Outstanding, Above Average, Satisfactory, Marginal, or Unacceptable) to assess fourteen performance criteria, including contract compliance, timeliness in filling medical positions, management effectiveness, quality control, flexibility, reliability, responsiveness to technical direction, and invoice accuracy. Evaluators must also respond to yes/no questions regarding cure notices, contract award willingness, customer satisfaction, problem notification, professionalism, and responsiveness. Additional remarks are required if ratings of Marginal or Unacceptable are selected. The survey collects identifying information for the evaluated offeror, contract number, evaluator credentials, and the evaluator's company affiliation and contact details.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| QUESTIONS AND ANSWERS FOR RFQ 36C24926Q0140-MAR12.docx | DOCX document | |
| 36C24926Q0140 0002.docx | DOCX document | |
| 36C24926Q0140 0001.docx | DOCX document | |
| 36C24926Q0140_1.docx | DOCX document | |
| ATTACHMENT D.5 - ONBOARDING FLOWCHART.pdf | ||
| ATTACHMENT D.1 - QASP.pdf | ||
| ATTACHMENT D.3 - CONFLICT OF INTEREST CERTIFICATION STATEMENT.pdf | ||
| ATTACHMENT D.2 - CONTRACTOR CERTIFICATION IMMIGRATION AND NATIONALITY ACT OF 1952 AS AMENDED.pdf | ||
| 36C24926Q0140 - 621 - Anesthesiology Services.docx | DOCX document |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Attachment D.4 – Past Performance Survey
Past Performance Survey
Please have evaluator complete and email directly to Ramona Bonness at ramona.bonness@va.gov by March 18, 2026 at 11:00AM CT. Surveys will not be accepted if sent by the Offeror.
Name of Offeror Evaluated:
Contract Number:
Evaluator’s Full Name:
Evaluator’s Position held or function in relation to project:
Evaluator’s Company/Organization Name, Address and Phone number:
Evaluator’s email address:
Reference Instructions: Your comments would be appreciated regarding this vendor’s past performance.
Please evaluate the Past Performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, provide additional information in the appropriate block or in the remarks section of this form.
O = Outstanding Performance greatly exceeded contract requirements
A = Above Average Performance exceeded contract requirements
S = Satisfactory Performance met 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
Describe exactly what type of Outpatient Clinic Services or similar service(s) were provided to your company/organization?
Length of the Service (Provide dates):
| Rate the following questions if the company provided temporary medical staffing or similar services. Provide information/comments in the Remarks Section below. |
| Highlight One |
Q1. To what extent did the Contractor comply with contract requirements?
O A S M U
Q2. How timely was the Contractor’s performance when filling medical positions needed?
O A S M U
Q3. Rate the effectiveness of the Contractor’s management of the contract?
O A S M U
Q4. Quality Control: Rate the overall quality of Contractor’s work.
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, explain on the following page.
Yes No
Q9. Would you award another contract to this Contractor? If no, explain on the following page.
Yes No
Q10. Was the customer satisfied with the service provided? If no, explain on the following page.
Yes No
Q11. To what extent did Contractor notify you of problems of potential issues?
O A S M U
Q12. Did the Contractor submit accurate invoices during the performance period?
Yes No
| Q13. Was the Contractor professional and courteous in its interaction with you? |
| Yes No |
Q14. Did the Contractor respond promptly to requests?
Yes No
Past Performance Survey – Remarks Section
Evaluator’s Additional Remarks regarding services:
Signature of Evaluator:
Print Name of Evaluator:
File details come from the government source that posted it. Updated .