ATTACHMENT D.6 - PAST PERFORMANCE QUESTIONNAIRE.docx
DOCX document 22 KB Posted
- Solicitation number
- 36C24925R0031
About this file
This document is a Past Performance Questionnaire for a VA contract solicitation (RFP 36C24925R0031) for Plastic Surgery Physician Services. The questionnaire is designed to evaluate contractor performance across multiple dimensions, including contract compliance, personnel appropriateness, schedule adherence, responsiveness, and reliability. The evaluation uses a standardized rating scale from "Outstanding" (O) to "Unacceptable" (U) for ten specific performance criteria, such as meeting contract requirements, technical responsiveness, and problem notification. The document is intended to be completed by a previous contract evaluator and submitted to the contracting specialist Laura Edelman, providing detailed insights into a contractor's past performance for a potential future VA contract in the Plastic Surgery Physician Services domain.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24925R0031 0001.docx | DOCX document | |
| S05 Vendor Questions.docx | DOCX document | |
| ATTACHMENT D.5 - ORG CONFLICT OF INTEREST.pdf | ||
| 36C24925R0031.docx | DOCX document | |
| ATTACHMENT D.3 - CONTRACTOR CERTIFICATION.pdf | ||
| ATTACHMENT D.2 - RULES OF BEHAVIOR.pdf | ||
| ATTACHMENT D.1 - QUALITY ASSURANCE SURVEILLANCE PLAN.pdf | ||
| ATTACHMENT D.4 - STATEMENT OF COMMITMENT AND UNDERSTANDING.pdf |
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Attachment D.6 – Past Performance Questionnaire
RFP 36C24925R0031
PAST PERFORMANCE QUESTIONNAIRE
REFERENCE INSTRUCTIONS: The Network Contracting Office 9 is soliciting for award of a VA contract for Plastic Surgery 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 Plastic Surgery Physician 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. Provide additional information in the appropriate block or in the remarks section of this form to justify your ratings.
“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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