ATTACHMENT D Past Performance Questionnaire Home Oxygen.docx
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- Solicitation number
- 36C24226R0081
About this file
This is a Past Performance Questionnaire template designed for evaluating contractors' performance on home oxygen services contracts with the Department of Veterans Affairs, New York/New Jersey VA Health Care Network (VISN 2).
The questionnaire is completed in two sections: the offeror provides general contract information including their name, point of contact, contract number, estimated dollar value, period of performance, and scope of services; the evaluator then completes reference information and rates the contractor's performance across thirteen rated criteria and four yes/no questions. The evaluation criteria assess compliance with contract requirements, technical expertise, Joint Commission standards compliance, contract management effectiveness, schedule adherence and response times, report accuracy, personnel appropriateness, billing timeliness and accuracy, customer satisfaction, problem notification, responsiveness to technical direction, flexibility to changing needs, and overall professional performance. Additional assessment areas include whether the contractor required excessive oversight, received cure or show cause notices, and whether the reference would award another contract to the contractor. Ratings use a five-point scale (Unsatisfactory, Marginal, Satisfactory, Very Good, Exceptional) plus a Neutral option for cases where no performance record exists. Completed questionnaires must be returned to the Contract Specialist, Corey Swinton, at Corey.Swinton@va.gov by a specified deadline, with instructions that responses are source selection sensitive and evaluator names will not be disclosed per Federal Acquisition Regulation 15.506.
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ATTACHMENT D – PAST PERFORMANCE QUESTIONNAIRE
A. GENERAL INFORMATION (Completed by Offeror):
Offeror’s Name and Address:___________________________________________________________________ Point of Contact: __________________________________________
| Contract Number: ________________________ | Estimated Dollar Value:__________________________ | |
| Period of Performance: Start Date:_______________________ | End Date:________________________ |
Scope of Services (e.g., geographic coverage area, frequency of services, etc.):
B. REFERENCE INFORMATION (Completed by Evaluator):
Company Name: ____________________________________________________________________________ Reference Name & Title: ______________________________________________________________________ Phone Number:_________________________ Email Address:_______________________________________ C. REFERENCE INSTRUCTIONS: The Department of Veterans Affairs, New York/New Jersey VA Health Care Network (VISN 2) is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. The intent of this questionnaire is to evaluate the Offeror’s performance regarding Home Oxygen Services. Your comments are considered Source Selection Sensitive; therefore, you are advised that Federal Acquisition Regulation (FAR) 15.506 prohibits the release of the names of the individuals providing reference information about the Offeror’s past performance. Please complete the survey below and return to Corey Swinton, Contract Specialist, at Corey.Swinton@va.gov no later than XXXXXXXXXXXXXXXXXX.
Please evaluate the Offeror’s past performance using the following rating system without variation. If a rating of Marginal or Unsatisfactory is selected, provide additional information in the appropriate block or in the remarks section of this form.
| UNSATISFACTORY |
| MARGINAL |
| SATISFACTORY |
| VERY GOOD |
| EXCEPTIONAL |
| NEUTRAL |
| Performance did not meet most contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective. |
| Performance did not meet some contractual requirements. There were problems, some of a serious nature, for which corrective action was only marginally effective. |
| Performance met contractual requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory. |
| Performance met all contract requirements and exceeded some to your benefit. There were a few minor problems, which the contractor resolved in a timely, effective manner. |
| Performance met all contractual requirements and exceeded many to your benefit. Problems, if any, were negligible and were resolved in a timely, highly effective manner. |
| No record of past performance or record is inconclusive. |
| ID # |
| Question |
| Select Rating |
| Q1. |
| To what extent did the Contractor comply with contract requirements? |
| U/ M/ S/ V/ E/ N |
Q1. Remarks
| Q2. |
| To what extent did the Contractor display technical expertise? |
| U/ M/ S/ V/ E/ N |
Q2. Remarks
| Q3. |
| To what extent did the Contractor comply with Joint Commission standards? |
| U/ M/ S/ V/ E/ N |
Q3. Remarks
| Q4. |
| Rate the effectiveness of the Contractor’s management of the contract. |
| U/ M/ S/ V/ E/ N |
Q4. Remarks
| Q5. |
| To what extent was the Contractor able to meet the performance schedule and required response times? |
| U/ M/ S/ V/ E/ N |
Q5. Remarks
| Q6. |
| If reports were required, were they accurate and in compliance with contract requirements? |
| U/ M/ S/ V/ E/ N |
Q6. Remarks
| Q7. |
| To what extent did the Contractor use appropriate personnel in the provision of services? |
| U/ M/ S/ V/ E/ N |
Q7. Remarks
| Q8. |
| To what extent was the billing process timely, complete, and accurate? |
| U/ M/ S/ V/ E/ N |
Q8. Remarks
| Q9. |
| To what extent did the Contractor meet customer satisfaction expectations? |
| U/ M/ S/ V/ E/ N |
Q9. Remarks
| Q10. |
| To what extent did the Contractor notify you of problems or potential issues? |
| U/ M/ S/ V/ E/ N |
Q10. Remarks
| Q11. |
| To what extent was the Contractor responsive to technical direction? |
| U/ M/ S/ V/ E/ N |
Q11. Remarks
| Q12. |
| To what extent was the Contractor flexible to changing needs? |
| U/ M/ S/ V/ E/ N |
Q12. Remarks
| Q13. |
| How would you rate the Contractor’s overall performance throughout the contract? |
| U/ M/ S/ V/ E/ N |
Q13. Remarks
| Q14. |
| Did the Contractor perform in a professional manner? If no, please explain in remarks. |
| Yes/No |
Q14. Remarks
| Q15. |
| Did the Contractor require a significant amount of oversight to ensure the service was rendered in accordance with contract requirements? If yes, please explain in remarks. |
| Yes/No |
Q15. Remarks
| Q16. |
| Was the Contractor ever issued a cure or show cause notice, or any other notice of subpar performance, regarding this contract? If yes, please explain in remarks. |
| Yes/No |
Q16. Remarks
| Q17. |
| Would you award another contract to this Contractor? If no, please explain in remarks. |
| Yes/No |
Q17. Remarks
Additional Remarks:
Signature of Reference: _______________________________________________ Date: _____________________
Please email completed questionnaire directly to Corey.Swinton@va.gov or fax to 838-433-7507 DO NOT return survey to the Contractor you are evaluating.
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