D.2 PAST PERFORMANCE QUESTIONNAIRE.Upadted.pdf

D.2 ATTACHMENT– 36C25622Q0525 PAST PERFORMANCE QUESTIONNAIRE

PAST PERFORMANCE QUESTIONNAIRE

1. The Contractor identified below has requested that you complete a past performance questionnaire on their behalf. This questionnaire will be used by the Contracting Officer, Frank Mendoza, to assess the likelihood that the Contractor will perform successfully providing Anatomic Pathology Referral Laboratory Services specializing in renal biopsy. Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME

REFERENCED CONTRACT #

2. Scope. The contractor shall provide all Anatomic Pathology Laboratory Testing Specializing in Renal Biopsy and be able to perform the following services and stains in house due to the critical nature, possible long-term complications, and the ability to determine what additional studies/stains are required or not for accurate diagnosis, at each step in the process, based on their pathological finding seen during analysis.

3. GENERAL INFORMATION: (Completed by Reference of Contractor being evaluated)

Name of Government or Commercial Organization:

Address:

Contract Number:

Brief Description:

Contractor Performed as: Prime Contractor Sub-Contractor Dates of Performance (if current include expiration):

Total Cost of Contract: Award/Incentive/Deduction Any terminations for cause or default? Circle YES or NO If yes, brief explanation:

Point Of Contact/COR:

Title:

Telephone Number:

Point of Contact’s email address:

4. Please answer the following questions pertaining to the relevancy of the services provided to you as compared to the description in paragraph 2.

Q1. Did the contractor provide Laboratory Testing Services (Y/N)?

5. Please use the below matrix to answer questions relating to performance using the following template.

Please evaluate the past performance using only the following ratings without variation. If the rating is Outstanding, Excellent, Good, 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 minimum performance or capability requirements in a way beneficial to the Government.

“E” = Excellent = Performance exceeded the minimum performance or capability requirements in a way beneficial to the Government.

“A” = Acceptable = Performance met the minimum performance or capability requirements.

“M” = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory

“U” = Unacceptable = Performance fails to meet the performance or capability requirements.

Please write in “not applicable” or “neutral” if unable to rate a certain question. For any E, G, M, or U rating please provide a short summary explanation of rating.

Please rate and provide information/comments for the following: Circle one Q1. To what extent did the contractor comply with overall contract requirements?

O E A M U

Q2. How successful was the Contractor in required referral tests? O E A M U

Q3. How would you rate the quality of the services provided by this Contractor in terms of technical competence and reliability

O E A M U

Q4. To what extent was the Contractor able to meet unexpected and short notice changes and/or requirements.

O E A M U

Q5. How would you rate the Contractor’s administrative staff as pertains to communication with your organization’s key personnel?

O E A M U

Q6. Did you issue any cure notices, show cause letters, or suspension of payment? If yes, please explain.

Yes No

Q7. Would you award another contract to the Contractor being evaluated? If no, please explain:

Yes No

Q8. Additional Comments pertaining to contractor performance:

Printed Name & Signature of Evaluator Date

6. Thank you for your time! Please return completed questionnaire to Frank Mendoza, Contracting Specialist for this acquisition, at francisco.mendoza@va.gov not later than the date specified in the 1449 Page 1 Block 8. For any questions, please call me at 713-791-1414 x22769.

mailto:francisco.mendoza@va.gov