ATTACHMENT F PAST PERFORMANCE QUESTIONNAIRE.pdf

PAST PERFORMANCE QUESTIONNAIRE (PPQ)

Radiation Safety Officer (RSO) Services

Orlando VA Healthcare System (OVAHCS)

Solicitation No.: [INSERT SOLICITATION NUMBER]

INSTRUCTIONS

To the Offeror: Complete Part I of this questionnaire and forward it to your identified point of contact (customer/client reference). Request that the reference complete Parts II through V and return the completed questionnaire directly to the Contracting Officer at the email address below no later than [INSERT DUE DATE].

To the Reference/Evaluator: Thank you for taking the time to complete this questionnaire. Your candid responses will assist the U.S. Department of Veterans Affairs in evaluating the past performance of an Offeror competing for a Radiation Safety Officer services contract. Please complete Parts II through V and return this form directly to the Contracting Officer. Do not return the completed form to the Offeror.

Return Completed Form To:

Contracting Officer: [INSERT NAME]

Email: [INSERT EMAIL]

Phone: [INSERT PHONE]

PART I – TO BE COMPLETED BY THE OFFEROR

Offeror Information

Field Response

Offeror/Company Name

DUNS / UEI Number

CAGE Code

Address

Field Response

Point of Contact

Phone / Email

Contract Being Referenced

Field Response

Contract Number

Contract Title

Awarding Agency / Customer

Prime or Subcontractor ☐ Prime ☐ Subcontractor

Total Contract Value $

Period of Performance Start: _______ End: _______

Type of Contract ☐ FFP ☐ T&M ☐ IDIQ ☐ Other: _______

Brief Description of Scope

Facility and Modality Information

Field Response

Type of Facility

Supported

☐ VA Medical Center ☐ DoD/MTF ☐ Civilian Hospital ☐ Academic Medical

Center ☐ Other: _______

Number of Sites

Covered

Radiation Modalities

Overseen

☐ Nuclear Medicine ☐ Linear Accelerator ☐ CT Simulator ☐ Fluoroscopy ☐ Diagnostic X-Ray ☐ Mammography ☐ Brachytherapy ☐ Other: _______

NRC License Type ☐ NRC Broad Scope ☐ NRC Specific ☐ Agreement State ☐ N/A

Named RSO on

License?

☐ Yes ☐ No

Field Response

Key Personnel

Provided

Name(s): __________ Certifications: __________

PART II – TO BE COMPLETED BY THE REFERENCE

Reference/Evaluator Information

Field Response

Name

Title / Position

Organization

Phone Number

Email Address

Role During Contract ☐ Contracting Officer ☐ COR ☐ Program Manager ☐ Radiation Safety

Committee Chair ☐ Chief of Nuclear Medicine ☐ Other: _______

Length of Time Familiar with

Offeror's Performance

PART III – PERFORMANCE RATING

Please rate the Offeror's performance in each of the following areas using the rating scale below.

If an area does not apply, mark "N/A."

Rating Scale

Rating Definition

E – Exceptional Performance meets contractual requirements and exceeds many to the Government's benefit. Few minor problems, if any, and corrective actions taken were highly effective.

Rating Definition

VG – Very Good Performance meets contractual requirements and exceeds some to the Government's benefit. Few problems, and corrective actions taken were effective.

S – Satisfactory Performance meets contractual requirements. Any problems encountered were minor, and corrective actions taken were satisfactory.

M – Marginal Performance does not meet some contractual requirements. Problems encountered required Government intervention, and corrective actions were only partially effective.

U –

Unsatisfactory

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. Serious problems for which corrective actions were ineffective.

N/A Not applicable or unable to assess.

Section A: Quality of Service

# Performance Element E VG S M U N/A

1 Quality of radiation safety program oversight and technical work ☐ ☐ ☐ ☐ ☐ ☐

2 Accuracy of surveys, wipe tests, and calibrations ☐ ☐ ☐ ☐ ☐ ☐

3 Adherence to ALARA principles per 10 CFR 20.1101(b) ☐ ☐ ☐ ☐ ☐ ☐

4 Quality of shielding design reports and dose calculations ☐ ☐ ☐ ☐ ☐ ☐

5 Compliance with ACR, AAPM, and TJC standards ☐ ☐ ☐ ☐ ☐ ☐

6 Effectiveness of annual radiation safety training ☐ ☐ ☐ ☐ ☐ ☐

Comments on Quality of Service:

Section B: Regulatory Compliance

# Performance Element E VG S M U N/A

7 Compliance with 10 CFR Part 20 (Standards for Protection Against

Radiation)

8 Compliance with 10 CFR Part 35 (Medical Use of Byproduct Material) ☐ ☐ ☐ ☐ ☐ ☐

9 Compliance with FDA (21 CFR 1020.30, 21 CFR 900) requirements ☐ ☐ ☐ ☐ ☐ ☐

10 Compliance with OSHA 29 CFR 1910.1096 ☐ ☐ ☐ ☐ ☐ ☐

11 Timely and accurate preparation of NRC/state license correspondence and amendments

12 Investigation and reporting of overexposures, misadministrations, spills, and medical events

Were there any Notices of Violation, enforcement actions, or unresolved regulatory findings during the period of performance? ☐ Yes ☐ No

If yes, please describe:

Section C: Schedule and Deliverables

# Performance Element E VG S M U N/A

13 Timeliness in submitting Quality Control Plan (QCP) ☐ ☐ ☐ ☐ ☐ ☐

14 Timeliness of quarterly Radiation Safety Committee reports ☐ ☐ ☐ ☐ ☐ ☐

15 Timely signing and submission of RSC meeting minutes ☐ ☐ ☐ ☐ ☐ ☐

16 Timeliness of annual program reviews and leadership briefings ☐ ☐ ☐ ☐ ☐ ☐

17 Accuracy and completeness of recordkeeping (inventory, personnel dosimetry, waste disposal)

18 Timely completion of annual inspections of radionuclide use and storage areas

Comments on Schedule and Deliverables:

Section D: Key Personnel and Staffing

# Performance Element E VG S M U N/A

19 Qualifications of key personnel (board-certified/eligible health physicists)

20 Maintenance of required certifications (Health Physics Society, MRSO) throughout POP

21 Retention/continuity of key personnel; management of turnover ☐ ☐ ☐ ☐ ☐ ☐

22 Compliance with facility security, background investigation, and privacy training requirements

Was the key RSO named on the license/permit throughout the period of performance? ☐ Yes

☐ No

If no, please explain any gaps:

Section E: Emergency Response

# Performance Element E VG S M U N/A

23 On-call availability during Weekend, Holiday, Evening, Night (WHEN) hours

24 Responsiveness to phone notifications (within 1 hour) ☐ ☐ ☐ ☐ ☐ ☐

25 On-site response to declared emergencies (within 3 hours) ☐ ☐ ☐ ☐ ☐ ☐

26 Effectiveness in classifying and managing radiation-related incidents ☐ ☐ ☐ ☐ ☐ ☐

Comments on Emergency Response:

Section F: Business Relations and Management

# Performance Element E VG S M U N/A

27 Communication and responsiveness to the Contracting Officer, COR, and Government POCs

28 Cooperation and problem-resolution during progress meetings ☐ ☐ ☐ ☐ ☐ ☐

29 Proactive identification of issues and recommendation of corrective actions

30 Effectiveness of the contractor's Quality Control Plan ☐ ☐ ☐ ☐ ☐ ☐

31 Professionalism and conduct of contractor personnel on-site ☐ ☐ ☐ ☐ ☐ ☐

Comments on Business Relations:

Section G: Cost Control and Invoicing

# Performance Element E VG S M U N/A

32 Timeliness and accuracy of invoices per FAR 32.905(b) ☐ ☐ ☐ ☐ ☐ ☐

33 Adherence to negotiated pricing and no billing for "no show" days ☐ ☐ ☐ ☐ ☐ ☐

34 Control of costs within contract value ☐ ☐ ☐ ☐ ☐ ☐

Comments on Cost Control:

PART IV – NARRATIVE ASSESSMENT

1. Please describe the Offeror's greatest strengths on this contract:

2. Please describe any weaknesses or areas where the Offeror needed improvement:

3. Were there any significant performance problems? If yes, describe the problem, the corrective actions taken, and their effectiveness:

4. Was the contract completed on time and within budget? ☐ Yes ☐ No ☐ Ongoing

If no, please explain:

5. Was the contract ever terminated (for default, cause, or convenience) or subject to a cure notice, show cause notice, or negative CPARS rating? ☐ Yes ☐ No

If yes, please describe:

6. Would you award another contract of similar scope to this Offeror? ☐ Yes ☐ No ☐ With

Reservations

Please explain:

PART V – OVERALL PERFORMANCE ASSESSMENT

Considering all factors, please provide your overall rating of the Offeror's performance on this contract:

☐ Exceptional ☐ Very Good ☐ Satisfactory ☐ Marginal ☐ Unsatisfactory

Additional comments the Government should consider in evaluating this Offeror's past performance:

CERTIFICATION

I certify that the information provided in this questionnaire is accurate and complete to the best of my knowledge.

Field Response

Evaluator Signature ______________________________

Printed Name ______________________________

Title ______________________________

Organization ______________________________

Date ______________________________

Privacy Act Notice: The information provided in this questionnaire will be used solely for the purpose of evaluating the Offeror's past performance in connection with the referenced solicitation. Responses will be protected from unauthorized disclosure to the maximum extent permitted by law.

Thank you for your time and candid assessment.

End of Past Performance Questionnaire