Attachment F -References.pdf

96 KB Posted

Attached to
RFA-Nursing Facility Client Care Surveyors
Solicitation number
S-10000-00011335
Issued by
Oregon

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Written by GovTribe AI ·

This is a Reference Check Form (Attachment F) for Solicitation #10000-00011335 (RFA5936) for Nursing Facility Client Care Surveyors, issued by DAS Procurement Services. The document is dated December 9, 2016, and serves as a standardized reference evaluation form for applicants to the solicitation.

The form requires basic information including the applicant's name, reference entity details, and contact information, followed by three specific evaluation questions rated on a scale of 0-10 (where 0 = Not satisfied, 5 = Moderately satisfied, and 10 = Extremely satisfied). The questions assess the applicant's overall quality of services and relationship, delivery of service, and responsiveness to customer service issues and special requests. Each question includes space for numerical scores and written comments.

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Other files

File Type Posted
Attachment E-Responsibility Inquiry.pdf PDF
S-10000-00011335~2.pdf PDF
S-10000-00011335-2 Addendum.pdf PDF
Attachment D-Disclousure.pdf PDF
S-10000-00011335-1 RFA.pdf PDF
S-10000-00011335-2 RFA.pdf PDF
Attachment G-Certified Disadvantaged Business Outreach Plan.pdf PDF
Attachment H-Sample Contract.pdf PDF
Attachment A-Applicant Information and Certification Sheet.pdf PDF
Equity NorthStar.pdf PDF
S-10000-00011335-1 Addendum.pdf PDF
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Solicitation #10000-00011335 (RFA5936) Nursing Facility Client Care Surveyors Att. F

DAS Procurement Services, Version 2.0 – December 9, 2016 Page 1 of 1

ATTACHMENT F - REFERENCE CHECK FORM

Applicant Name: __________________________________________

Reference Entity: __________________________________________

Reference Contact Name: __________________________________________

Contact Telephone Number: __________________________________________

Contact Email Address: __________________________________________

Please rate the following questions on a scale of 0-10:

0 = Not satisfied 5 = Moderately satisfied 10 = Extremely satisfied.

1. How would you rate the Applicant’s overall quality of services provided and your overall relationship with the Applicant?

Score: __________

Comments: ______________________________________________________________________________

2. How would you rate the Applicant’s delivery of service?

Score: __________

Comments: ______________________________________________________________________________

3. How would you rate the Applicant’s responsiveness to customer service issues and special requests (e.g., reported problems, changes billing, etc.)?

Score: __________

Comments: ______________________________________________________________________________

File details come from the government source that posted it. Updated .