D 5 - Past Performance Questionnaire -SJ.pdf
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- Solicitation number
- 36C24826Q0604
About this file
This is a Past Performance Questionnaire template used by the San Juan VA Caribbean Healthcare System (SJVCHS) to evaluate vendor performance for Perfusion/Autotransfusion Services contracts.
The questionnaire is completed by previous customers or contract holders who have direct knowledge of a vendor's performance. Evaluators rate the vendor using a five-point scale: Outstanding (O), Above Average (A), Satisfactory (S), Marginal (M), and Unacceptable (U). The assessment covers two primary performance categories: Customer Satisfaction and Compliance with Staffing Requirements. Under Customer Satisfaction, evaluators rate the company's maintenance of professional staff, responsiveness to inquiries, flexibility in addressing urgent requirements, and overall customer satisfaction. Under Compliance with Staffing Requirements, evaluators assess the company's provision of adequate notice for personnel changes, consistent delivery of trained and qualified staff, and maintenance of staff qualifications and proficiency. Additional evaluation items include whether the company received cure or show cause notices and whether the evaluator would hire the company again. Completed questionnaires must be returned to Fernando G. Defillo at Fernando.defillo@va.gov by the date specified by the contractor. The form includes space for narrative explanations for all ratings, particularly for Marginal or Unacceptable ratings, and requires evaluator identification information including name, email, position, phone number, and company/city affiliation.
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PAST PERFORMANCE QUESTIONNAIRE
Perfusion/Autotransfusion Services
1. Background: The San Juan VA Caribbean Healthcare System (SJVCHS) has an ongoing requirement for Perfusion/Autotransfusion Services. The vendor has identified you as a reference to validate the their past performance. This questionnaire concerns past or current contracts 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 narrative explanation for your 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 the respective question. 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 the date that the contractor advises. Please return to Fernando G. Defillo email at Fernando.defillo@va.gov.
Name of Company: __________________________
Title/Description of services provided:
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
CUSTOMER SATISFACTION
mailto:brett.cook@va.gov
1. Company maintained a professional staff.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
2. Company was responsive to inquiries regarding contract/agreement.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
3. Company was flexible in responding to urgent requirements.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
4. Overall customer satisfaction.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
COMPLIANCE WITH STAFFING REQUIREMENTS
5. Company provided sufficient notice of personnel changes/additions, to ensure adequate time to credential personnel.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
6. Company consistently provided trained/qualified staff.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
7. Company ensured staff remained fully qualified/proficient at all times.
Outstanding Above Average Satisfactory Marginal Unacceptable
BRIEF EXPLANATION OF RATING GIVEN:
Additional Comments
8. Was the company ever issued a cure or show cause notice under the referenced contract/agreement?
If yes, explain in “comments.” Yes / No
Comments:
9. Would you hire this company again?
If no, explain in “comments.” Yes No
BRIEF EXPLANATION OF RATING GIVEN:
Overall Rating: _________________________________
Name of Evaluator: ______________________ E-Mail: ___________________________________
Position Title /Grade:_____________________ Phone Number: ____________________________
Company/City: ________________________Date questionnaire completed: _________________
PAST PERFORMANCE QUESTIONNAIRE
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