D.3 PAST PERFORMANCE SURVEY.pdf

FOR OFFICIAL USE ONLY --- SOURCE SELECTION SENSITIVE INFORMATION

PAST PERFORMANCE SURVEY

REFERENCE INSTRUCTIONS: The Department of Veterans Affairs, VISN-17, is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. The intent of this form is to evaluate Intersocietal Accreditation Commission (IAC) Vascular Lab Services. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation (15.506) prohibits the release of the names of individuals providing reference information about Offeror’s past performance. Survey should be completed by evaluator and returned no later than the closing date for the request for quote e-mailed to Laqulla.Howard@va.gov.

Name of Contractor being evaluated:

1. What services were provided? _________________________________________________

2. How long has your company had a contract with this contractor?

2. What was the total contract award amount?

3. Where is the location of this service?

4. Have there been late deliveries of performance or other unsatisfactory performance resulting in additional contractual or administrative costs?

Yes No

If yes, explain

D.5 PAST PERFORMANCE SURVEY - 36C25722R0061

Please evaluate the past performance using the following ratings without variation. If the rating is Marginal or Unacceptable, please provide additional information in the appropriate block or in the additional 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 contractor's performance were less than satisfactory

"U" = Unacceptable = Performance does not met the minimum contract requirements.

Please rate and provide information/comments for the following: Circle one

1. To what extent did the contractor comply with contract requirements? O A S M U

2. If reports were required, were they accurate in meeting contract requirements? O A S M U

3. To what extent did the contractor use appropriate personnel for contract requirements? O A S M U

4. To what extent did the contractor display technical expertise? O A S M U

5. Quality control: O A S M U

Please rate and provide information/comments for the following: Circle one

1. To what extent was contractor able to meet the performance schedule? O A S M U

2. What extent was contractor flexible in responding to changing needs? O A S M U

3. To what extent was the contractor reliable? O A S M U

4. To what extent was the contractor responsive to technical directions? O A S M U

5. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, please explain. O A S M U

1. Would you award another contract to the party being evaluated? If no, please explain. O A S M U

2. Was the customer satisfied with the end product? If no, please explain. O A S M U

3. To what extent did contractor notify you of problems or potential problems? O A S M U

Additional Remarks:

Signature of Reference: Date:

Print Name: Company:

Title: Telephone: