ATTACHMENT G PAST PERFORMANCE QUESTIONNARE.pdf

ATTACHMENT G: PAST PERFORMANCE QUESTIONNARE

Department of Veterans Affairs: 36C10G-20-X-XXXX EDI/P2E Processing

PART 1:

TO: Insert Name, Contracting Officer AGENCY: Insert Agency/Company Name

PHONE: Insert Phone E-MAIL: Insert E-mail

INFORMATION REQUEST: PAST PERFORMANCE

The Department of Veterans Affairs is currently in the process of awarding a competitive service contract.

[CONTRACTOR NAME] has provided this Questionnaire to you for a reference regarding

[CONTRACTOR NAME]’s record of past performance under Contract No. [CONTRACT #].

Send completed questionnaires to James.Modlin@va.gov and Glenn.BurtonJr@va.gov

NOTE TO VENDORS: If the Questionnaire is provided for Subcontractors reference, the

Vendor’s name below must include both the Prime and Subcontractor Names.

PART 2:

PAST PERFORMANCE QUESTIONNAIRE

Vendor’s Name:

Request for Quote: Electronic Data Interchange (EDI) and Paper-Based Health Clams and

Associated Medical Documentation (P2E)

Name of Person Completing the Evaluation:

Telephone: E-mail:

Title:

Company/Organization:

Please rate the vendor in each of the following areas. Note: there is room for comments where you deem remarks would be helpful to our evaluation.

• Not Applicable: N/A

• 1: Performance clearly below the contract performance standard or requirement

• 2: Performance occasionally does not meet minimum contract performance standard or requirement

• 3: Performance that meets the minimum contract performance standard or requirement mailto:James.Modlin@va.gov mailto:Glenn.BurtonJr@va.gov

• 4: Performance that meets and occasionally exceeds the contract performance standard or requirement

• 5: Performance that almost always exceeds the contract performance standard or requirement

1. Overall quality/satisfaction

N/A

1 2 3 4 5

Overall satisfaction with the Vendor’s performance.

2. Delivery performance

Delivery performance includes delivery consistency, on time performance, and flexibility in responding to emerging issues and implementing required solutions.

3. Satisfaction with the quality of service delivered

Rate the effectiveness and applicability of the plans and strategies delivered and the actual implementation of those.

4. Satisfaction with problem resolution

This includes the vendor’s ability to solve problems, the speed in which they handle problems, and their effective delivery of resolutions.

5. Satisfaction with the quality of contractor personnel

Rate the quality of the contractor’s staff in executing the project work scope.

7. Have you issued a cure notice, show cause notice, suspension of progress payments or other letters directing the correction of a performance problem in the past 3 years?

Yes No If Yes, please explain.

8. Have you terminated this contractor for default within the past 3 years, or are there any pending termination actions? Yes No If Yes, please explain.

9. Based on the vendor’s overall performance, would you award them another contract?

Yes No If No, please explain.

10. Have you discussed any adverse past performance problems with the Vendor and given them an opportunity to comment? Yes No Please explain.

11. Do you file past performance information in a database that the Contracting Officer may search? Yes No Please explain.

12. If the contract had options, were those options exercised? Yes No Please explain.

13. What was the contract period of performance (i.e., when were services provided)?

14. What was the dollar value of the contract performed by the vendor?

15. Provide a brief description of the services provided by the vendor for this contract.

Please attach any past performance database reports or other material you deem appropriate for a full understanding of the Vendor’s past performance by the evaluator. Please provide information on any adverse performance by the contractor and the corrective actions taken.