D.2 Past Performance Questionnaire.docx

D.2 PAST PERFORMANCE QUESTIONNAIRE

PAST PERFORMANCE QUESTIONNAIRE

I. INTRODUCTION:

This questionnaire is designed to collect past performance information on offerors competing for award of a contract for Community Based Outpatient Clinic services for Veterans on the island of Molokai for the VA Pacific Islands Health Care System (VA PIHCS). Please complete the enclosed questionnaire and return it directly to Veterans Affairs by the date and time listed in block 8 of the SF1449 pertaining to this Solicitation. For assistance with this form or to request an electronic copy notify the contracting specialist listed below. Handwritten responses will be accepted. If you need more space than provided, please attach additional pages or write on the last page. Include only relevant information. Responses will be treated as source selection sensitive. Return the questionnaire either by fax or email to the following addresses:

Attn: April Gonzales E-mail: april.gonzales@va.gov

II. CUSTOMER/CLIENT IDENTIFICATION:

The following information pertains to the organization and contract information of the customer completing the questionnaire:

Your company or agency name: ___________________________________________________ Name of contractor being evaluated: _______________________________________________ Your contract number: __________________ Total value of your contract: $ _____________________ Performance Period: Basic Period: ____________________ Option Periods: _____________________ Brief description of services provided: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

III. EVALUATOR INFORMATION:

The following information pertains to the person completing this questionnaire.

Name/Title: __________________________________________________________________________ Company’s Name: __________________________________________________________________ Phone Number: _________________Email address: _____________________________

IV. EXPLANATION OF CODES:

In Section V below of this questionnaire we ask 12 questions regarding your contractor’s performance. Please use the following ratings when rating the contractor’s performance:

V. QUESTIONS CONCERNING PAST PEFORMANCE:

Place an “X” in the appropriate box next to the letter for each item on the questionnaire. Narrative statements are vital. Please provide a supporting narrative for each area. Attach additional pages if there is insufficient space in the comment space.

1. What level of supervision does your contract require?

Little |_| None |_| Other ____________________________

2. How would you rate the contractor’s overall performance?

E |_| V |_| S |_| M |_| U |_| N |_| Please explain if rated less than satisfactory: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. How would you rate the contractor’s timeliness in providing Transitional /Emergency Shelter Beds and Case Management Services?

E |_| V |_| S |_| M |_| U |_| N |_| Remarks: _______________________________________________________________________

4. Has the contractor ever had a problem with meeting the timeliness standards of the contract?

Yes |_| No |_| If timeliness is a problem, what was/were the cause(s) of delay? Has the contractor corrected the problem?

Comments for Question 4:

5. Rate the contractor’s ability to work with the various requirements i.e. Performance as timeliness of customer service, professionalism, adherence to rules, safety policies and local laws.

E |_| V |_| S |_| M |_| U |_| N |_| Comments for Question 5:

6. Rate the contractor’s professional knowledge and reliability during the performance period?

E |_| V |_| S |_| M |_| U |_| N |_| Comments for Question 6: __________________________________________________________________________________________________________________________________________________________________________

7. Have you experienced any problems with the contractor case managers, supervisors/managers, etc.?

Yes |_| No |_| Comments for Question 7:

8. Rate the contractor’s interaction with your organization; e.g. courteous, professional, proper sense of urgency to your needs, timeliness, etc.

E |_| V |_| S |_| M |_| U |_| N |_| Comments for Question 8:

9. Has this contract been partially or completely terminated for default or convenience or are there any pending terminations?

Yes |_| No |_| DEFAULT |_| CONVENIENCE |_| If yes, explain (e.g., inability to meet cost, timeliness, customer service, performance, or delivery schedules).

Comments for Question 9:

10. Did you make any significant changes in service or procedures during the life of the contract? If so, what were the changes?

Yes |_| No |_|

11. What is your overall rating of the contractor?

Explain why you would NOT :

Additional Comments:

Return documents to: april.gonzales@va.gov Source Selection Information – See FAR 3.104