ATTACHMENT D PAST PERFORMANCE QUESTIONNAIRE.doc

ATTACHMENT D – PAST PERFORMANCE QUESTIONNAIRE

36C25622Q1322

INSTRUCTIONS FOR THE

PAST PERFORMANCE QUESTIONNAIRE

FOR OFFICIAL USE ONLY

CONTRACTOR INFORMATION (Information on the Company that you are evaluating) A. Contractor Name:

B. Contractor's Address:

C. Point of Contact:

CONTRACT INFORMATION:

IN ORDER TO DETERMINE RELEVANCY, AND RECENCY THE FOLLOWING DATA IS REQUIRED. FAILURE TO PROVIDE THIS INFORMANTION MAY RENDER THE PROPOSAL UNRESPONSIVE.

A. CONTRACT NUMBER:

B. CONTRACT TYPE:

C. AWARD DATE:

D. PERIOD OF PERFORMANCE:

E. TOTAL CONTRACT DOLLAR AMOUNT INCLUDING

OPTIONS, IF APPLICABLE: $________________

F. SCOPE: PLEASE INCLUDE A BRIEF DESCRIPTION OF THE SERVICES PERFORMED TO DETERMINE SIMILARITY OF SCOPE.

PAST PERFORMANCE QUESTIONNAIRE

FOR OFFICIAL USE ONLY

1. Please complete this questionnaire based on the following guidance:

a. For each question please select a rating as defined below from the dropdown menu. Choose "N/A" from the dropdown menu if you are unable to provide a rating for an area. Assessments should reflect only contractor liable performance. The following is a definition of the scoring levels:

Rating

Definition

b. Handwritten remarks are encouraged. Space is provided at the end of the survey. If more space is needed, please provide information on a separate sheet of paper.

c. You are urged to supplement your own knowledge of the contractor's performance with the judgment of others in your organization. In addition to completing the attached questionnaire for the identified program, we solicit your comments on other contracts/programs that your activity has with this offeror.

2. Please return completed questionnaire no later than due date for submission of this solicitation, 36C25622Q1322 e-mail to:

GULF COAST VETERANS HEALTH CARE SYSTEM

Network Contracting Office (NCO) 16 ATTN: Danette Rene’ Impey

400 VETERANS AVENUE

BILOXI, MS 39531-2410

EMAIL: rene.impey@va.gov

PAST PERFORMANCE QUESTIONNAIRE

FOR OFFICIAL USE ONLY

QUALITY OF SERVICE

1. Contractor's compliance with contractual terms and conditions.

Choose an item.

2. Quality of contractor furnished reports/deliverables.

Choose an item.

3. Overall rating of contractor's commitment to providing quality service.

Choose an item.

4. Contractors ability to meet standards specified for performance.

Choose an item.

5. Overall rating of contractor's quality of service.

Choose an item.

TIMELINESS OF PERFORMANCE

1. Contractor's ability to meet specific response times and scheduled Choose an item.

time frames for completion of specific tasks.

2. Contractor's responsiveness/timeliness for providing administrative Choose an item.

reports/documents required by the contract.

3. Contractor's timeliness in responding to emergency service requirements.

Choose an item.

4. Overall rating of contractor's responsiveness/timeliness.

Choose an item.

BUSINESS RELATIONS

1. Contractor's ability to identify problems and potential problems and Choose an item.

promptly notify the Contracting Officer.

2. Contractor's ability to correct problems and prevent or mitigate potential Choose an item.

problems in a timely manner.

3. Contractor's willingness to improve and correct noncompliance issues Choose an item.

or concerns.

4. Extent to which the contractor has demonstrated reasonable and cooperative behavior.

Choose an item.

5. Contractor's ability to use effective approaches and provide technical expertise and resources to solve contract problems.

6. Contractor's working relationship with the Contracting Officer, quality assurance personnel, and customers.

7. Contractor's flexibility in satisfying the requirements of its customers.

8. Extent to which the contractor provided prompt and courteous service when responding to customer complaint.

9. Overall rating of customer satisfaction.

10. Overall rating of business relations.

MANAGEMENT OF KEY PERSONNEL

1. Contractor's ability to select and retain cooperative and effective key personnel, such as the contract manager and quality control personnel.

2. Extent key personnel were knowledgeable about contractual requirements.

3. Contractor's ability to meet appropriate staffing levels with qualified personnel in order to provide required services.

4. Contractor's ability to effectively manage subcontracts.

5. Overall rating of contractor's management of key personnel.

REMARKS CONCERNING CONTRACTOR’S OVERALL PERFORMANCE:

RESPONDENT’S PRINTED NAME: ____________________________________________

RESPONDENT’S TITLE: _____________________________________________________

RESPONDENT’S SIGNATURE: ________________________________________________

RESPONDENT’S PHONE NUMBER: ___________________________________________

FOR OFFICIAL USE ONLY

THANK YOU FOR TAKING THE TIME TO COMPLETE AND RETURN THIS QUESTIONNAIRE!

_1720437717.unknown