Attachment D Past Performance Questionnaire Med Gas.pdf
PDF 125 KB Posted
- Attached to
- 6830--Supply: Medical Gas/Cylinder Federal contract opportunity
- Solicitation number
- 36C24822Q0001
About this file
This document includes a past performance questionnaire for a federal solicitation seeking medical gas and cylinder delivery services. The North Florida/South Georgia VA Healthcare System is soliciting proposals for a base year and four one-year option periods for medical gas and cylinder delivery to its facilities and designated catchment area. Offerors are required to provide references that will be sent this past performance questionnaire to evaluate the offeror's performance on previous relevant contracts. The questionnaire asks references to rate the offeror's performance on a scale of outstanding to unacceptable for factors including staffing levels, quality of service, timeliness, quality control, and overall customer satisfaction. It also requests details about any cure notices, show cause notices or contract discrepancy reports issued on government contracts. References are asked if they would award to this contractor in the future and provide comments to explain their ratings. Completed questionnaires must be returned by June 29, 2021 to the contracting officer at the email address provided.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C24822Q0001_2.docx | DOCX document | |
| Medical Gas Q A.pdf | ||
| 36C24822Q0001 0001.pdf | ||
| 36C24822Q0001_1.docx | DOCX document | |
| Attachment C Price Cost Delivery Schedule Med Gas.pdf | ||
| Attachment B Statement of Need- Med Gas.pdf | ||
| Attachment A Combined Synopsis Solicitation- Med Gas.pdf |
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Text version
Attachment C 36C24822Q0001 Past Performance Questionnaire
PAST PERFORMANCE QUESTIONNAIRE
Request for Quote – 36C24822Q0001 Medical Gas/Cylinder Delivery
1. Background: The VA Network Contracting Office – 8, Gainesville, FL is conducting a competitive acquisition for Medical Gas and Cylinder Delivery for the North Florida/South Georgia Healthcare System and its designated catchment area. The quoter has identified you as a reference to validate the quoter’s past performance. This questionnaire concerns past or current contracts/agreements for which you have personal knowledge.
2. Instructions: Please complete this questionnaire based on the following guidance.
Please take the time to answer the questions to the best of your knowledge. Circle the responses that best describe the company’s performance and write in a short narrative explanation for your answer.
Use a N/A rating to indicate that you have no performance information for that area, or if the question does not apply to you. Handwritten (ink) responses are sufficient.
Please complete the following questionnaire to assist our evaluation of the company’s past performance and return no later than 4:30 PM (ET) on June 29, 2021 to Scott Brickey, email at scott.brickey@va.gov
Name of Company: U.S Department of Veteran Affairs – Network Contracting Office 8 Contracting Officer.
Title/Description:
Delivery of Medical Gas and Cylinders for the North Florida/South Georgia VA Healthcare System.
Please evaluate the past performance using only the following ratings without variation. If the rating is
Marginal or Unsatisfactory, 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 company’s performance were less than satisfactory
“U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements mailto:scott.brickey@va.gov
CUSTOMER SATISFACTION
1. Contractor maintained appropriate and professional staffing levels to meet the requirement.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
2. Quality of service and workmanship.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
3. Timeliness/Adherence to Delivery schedules.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
4. Quality Control.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
5. Overall customer satisfaction.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
6. If past performance information is from a Government contract, was the contractor ever issued a cure or show cause notice or contract discrepancy report? If so, give details and contract/agreement number?
If yes, explain in “comments.” Yes /No
Comments: ________________________________________________________________________
7. If given the opportunity would you award to this contractor?
If no, explain in “comments.” Yes /No
BRIEF EXPLANATION OF RATING GIVEN:
Name of Evaluator: _________________E-Mail: _______________________
Signature:
Position Title /Grade: ___________________ Phone Number: ____________________
Company/City: ______________________________________
Date questionnaire completed: __________________________
File details come from the government source that posted it. Updated .