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D.3 PAST PERFORMANCE SURVEY
36C25721Q0502– Locum Pathologist Service Contract
Past Performance Questionnaire: The past performance questionnaire must be independently completed by the offeror’s client references. Offerors are responsible for ensuring that their client references complete this questionnaire and submit it via email directly to lisa.edwards1@va.gov and carlos.leon@va.gov for 36C25721Q0502 – Locum Pathologist Service Contract in the subject line, NO LATER THAN THE DUE DATE AND TIME OF THE SOLICITATION.
PAST PERFORMANCE QUESTIONNAIRE
1. Contractor Name:
Role on Project: (Prime/Subcontractor):
2. Contract Number:
| 3. Contractor Address: | |
| 4. | Contract Type: |
| Firm Fixed Price | |
| T&M/LH | |
| Cost Reimbursement | |
| Other (Please Specify) | |
| 5. Agency/Company Name: |
| 6. Agency/Company POC/Phone/Email: |
| 7. Period of Performance: | |
| 8. | Dollar Amount at Award: $ |
| Annual Amount: $ | Total Dollar Value with Mods:$ | |
9. Title of Contract:
10. Description of Contract Service/Scope of Contract:
| 11. Complexity of Work: |
| Difficult: |
| Moderate: |
| Routine: |
NOTE: Please use adjectival ratings for items A – C and E – G below.
Item D uses a numerical ratings scale 1 to 5. Ratings guidelines are provided on pages 4 & 5.
| 12. Subject Area |
| 13. Comments (Attach additional sheets, if necessary.) |
| 14. Rating |
| A. Quality of Work |
| PLEASE PROVIDE COMMENTS, PARTICULARLY IF RATING ASSIGNED IS EXCEPTIONAL OR UNSATIFACTORY |
| B. Personnel – Knowledge, Skills and Abilities |
| PLEASE PROVIDE COMMENTS, PARTICULARLY IF RATING ASSIGNED IS EXCEPTIONAL OR UNSATIFACTORY |
| C. Cost/Budget Control |
| PLEASE PROVIDE COMMENTS, PARTICULARLY IF RATING ASSIGNED IS EXCEPTIONAL OR UNSATIFACTORY |
| D. Customer Satisfaction |
| PLEASE PROVIDE COMMENTS, PARTICULARLY IF |
RATING ASSIGNED IS “5” (highest) OR “1” (lowest) (1 – 5)
| E. Timeliness of Performance/ Deliverables |
| PLEASE PROVIDE COMMENTS, PARTICULARLY IF RATING ASSIGNED IS EXCEPTIONAL OR UNSATIFACTORY |
| F. Business Relations |
| PLEASE PROVIDE COMMENTS, PARTICULARLY IF RATING ASSIGNED IS EXCEPTIONAL OR UNSATIFACTORY |
| G. Overall Performance |
| PLEASE PROVIDE COMMENTS, PARTICULARLY IF ASSIGNED RATING IS EXCEPTIONAL OR UNSATISFACTORY |
15. Would you select this contractor again? Please explain. (Attach additional sheet if necessary.)
16. Name and title of individual who completed this questionnaire:
17. Date:
Past Performance Rating Guidelines
Summarize contractor performance in each of the rating areas. Assign each area a rating of Unsatisfactory, Marginal, Satisfactory, Very Good, and Exceptional. Use the following instructions as guidance in making these evaluations. Please use the comments area on the preceding form to justify the rating given.
| Ratings |
| Quality of Work/ Personnel Capabilities |
| Cost/Budget Control |
| Customer Satisfaction |
| Timeliness of Services/Deliverab les |
| Business Relations |
-Compliance w/contract requirements -Accuracy of reports -Appropriateness of personnel -Technical excellence
-Within budget -Current, accurate, complete billings -Relationship of negotiated costs to actual -Cost efficiencies -Change orders issued
Customer Satisfaction is a measure of how products and services supplied by a company meet or surpass customer expectation.
On a scale of 1-5 (5 being the highest) please rate and describe your level of satisfaction with the contractor’s performance.
-Met interim milestones -Reliable -Responsive to technical direction -Completed on time -Effective management -Business like correspondence -Responsive to contract requirements -Prompt notification of problems -Reasonable/ cooperative -Flexible -Pro-active
5 - Very satisfied
4 - Somewhat satisfied
3 - Neither satisfied nor dissatisfied
2 -Somewhat dissatisfied
1 - Very dissatisfied
| Unsatisfactory |
| Nonconformance's |
| Cost issues are |
| Delays are |
| Response is not |
| are comprising the |
| comprising |
| achievement of |
| performance |
achievement of contract requirements contract requirements
| Marginal |
| Nonconformance's require major agency resources to ensure achievement of contract requirements |
| Cost issues require major agency resources to ensure achievement of |
contract requirements
| Delays require major agency resources to ensure achievement of contract requirements |
| Response is marginally effective |
| Satisfactory |
| Nonconformance's do not impact achievement of contract requirements |
| Cost issues do not impact |
achievement of contract requirements
| Delays do not impact achievement of contract requirements |
| Response is usually effective |
| Very Good |
| There are no quality |
| There are no |
| There are no delays |
| Response to |
| problems/issues, and |
| cost |
inquiries and/or
| the contractor has |
| management |
technical, service,
| substantially exceeded |
| issues and the |
administrative
| the contract |
| Contractor has |
issues are effective.
| requirements without |
| contract |
| commensurate |
| requirements, |
| additional costs to the |
| achieving cost |
| Government |
| savings to the |
Government.
| Exceptional |
| The contractor has |
| The contractor |
| The contractor has |
| The contractor has |
| demonstrated an |
| demonstrated an |
| exceptional |
| demonstrated an |
| performance level that |
| exceptional |
| performance level. |
| performance level. |
| was significantly in |
| performance. It |
| It is expected that |
| It is expected that |
| excess of anticipated |
| is expected that |
| this rating will be |
| this rating will be |
| achievements and is |
| this rating will |
| used in those rare |
| used in those rare |
| commendable as an |
| be used in those |
| circumstances |
| circumstances |
| example for others. It |
| rare |
| where contractor |
| where contractor |
| is expected that this |
| circumstances |
| performance clearly |
| performance clearly |
| rating will be used in |
| where the |
| performance levels |
| performance levels |
| circumstances where |
| achieved cost |
| described as |
| described as |
| "Exceptional". |
| "Exceptional". |
| performance clearly |
| performance |
| exceeds the |
| clearly exceeds |
| performance levels |
| the performance |
| described as |
| levels described |
"Exceptional".