D 5 - Past Performance Questionnaire.pdf
PDF 234 KB Posted
- Attached to
- Q522--FY26: Teleradiology | West Palm Beach
- Solicitation number
- 36C24826Q0307
About this file
This is a Past Performance Questionnaire for Request for Quote 36C24826Q0307 issued by West Palm Beach Veterans Affairs Medical Center (WPBVAMC) for Teleradiology Services.
The questionnaire is distributed to references identified by vendors to validate their past performance on teleradiology service contracts. Respondents must rate contractor performance using a five-point scale: Outstanding (O), Above Average (A), Satisfactory (S), Marginal (M), and Unacceptable (U). Ratings of Marginal or Unacceptable require detailed explanatory comments. The questionnaire addresses seven evaluation areas: professional staff maintenance (radiologists and administrative personnel), timeliness of STAT/emergent exam interpretations, flexibility and responsiveness to inquiries and urgent requirements, radiologists' performance in communicating critical results to referring providers, sub-specialty coverage and expertise (neuroradiology, body imaging, MSK), system reliability and integration with PACS and EHR systems, and overall clinician satisfaction with teleradiology services. The final question asks whether the evaluator would choose to do business with the contractor again. Respondents must provide their name, email, position title/grade, phone number, company/city, and date of completion. Completed questionnaires should be returned to Fernando Defillo at Fernando.defillo@va.gov by the date specified by the contractor.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Attachment. D.5
PAST PERFORMANCE QUESTIONNAIRE
Request for Quote - 36C24826Q0307
Teleradiology Services
1. Background: The West Palm Beach Veterans Affairs Medical Center (WPBVAMC) has an ongoing requirement for Off-Site Teleradiology Services. The vendor has identified you as a reference to validate the their past performance. This questionnaire relates to past or current contractors/agreements for which you have personal knowledge of.
2. Instruction: 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 narrative explanation for you answer. Use a N/A rating to indicate that you have no performance information for that particular area, or if the question does not apply to you. Each question has space for your comments. If more space is needed, please attach additional sheets to the end of the questionnaire and reference to respective questions. Handwritten (ink) or typed responses are sufficient.
Please complete the following questionnaire to assist our evaluation of the company's past performance and return no later than the date the contractor advises. Please return to Fernando Defillo, Fernando.defillo@va.gov .
Name of Company: _____________________________________________
Title and Description of Project:
Please evaluate the past performance using only the following ratings without variation. If the ratings 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 meet 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:osetta.quinn@va.gov
CUSTOMER SATISFACTION
1. How would you rate the company in maintaining a professional staff? (e.g.., Radiologists and
Administrative Staff).
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
2. How would you rate the timeliness of STAT/emergent exam interpretations (e.g.., turn around times)?
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
3. How flexible and responsive was the Company in responding to inquiries and urgent requirements?
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
4. How would you rate the radiologists' performance and timeliness in communicating critical results to the referring provider?
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
4. How was the sub-specialty coverage and expertise when required (e.g.., neuroradiology, body imaging, MSK)?
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
5. How would you rate the system's reliability and how well it integrates with PACS and EHR systems?
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
6. How would you rate your overall satisfaction of your clinicians with the teleradiology services provided as a customer?
Outstanding Above Average Satisfactory Marginal Unacceptable BRIEF
EXPLANATION OF RATING GIVEN:
7. Given the opportunity, would you choose to do business with this contractor again for teleradiology services?
If yes, explain in “comments.” Yes/No
Comments: _____________________________________________________________________________________
Overall Rating: ____________________________________
Name of Evaluator: ______________________________
E-Mail:________________________Position Title/Grade: _____________________________
Phone Number: _______________________ Company/City: _____________________
Date Questionnaire Completed: ______________________
File details come from the government source that posted it. Updated .