D.31 Past Performance Questionnaire 02.pdf

D.31 PAST PERFORMANCE QUESTIONNAIRE

36C25923R0008

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 to assess the likelihood that the Offeror will perform successfully on an impending requirement for a Community Based Outpatient Clinic in Vernal Utah for the Salt

Lake City VA Health Care System, Salt Lake City Utah. Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME

REFERENCED CONTRACT #

2. Background. The Salt Lake City VA Health Care System, Salt Lake City, Utah has a need for the provision of

Primary Care services and Mental Health support for eligible Veterans living in Vernal Utah. The contractor shall furnish health care providers, medical facilities, equipment and supplies, emergency-fill pharmaceutical prescriptions, and administrative functions to fulfill the support of enrolled patients.

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 Value of Contract:

Any terminations for cause or default? Circle YES or NO

If yes, brief explanation:

Any contract discrepancy reports filed? Circle YES or NO

If yes, brief explanation:

Point of Contact/Contracting Officer’s Representative:

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 Primary Care Services and Mental Health Services (Y/N)?

Q2. If no, please provide a short description of the type of services provided including the number of FTE and /or number of patients served.

Q3. Did the contractor provide any additional services (Y/N)? If so, what types?

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 Excellent, Good, Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form.

“E” = Excellent = Performance greatly exceeded the contract requirements – High Confidence “G” = Good = Performance exceeded the contract requirements – High Confidence “S” = Satisfactory = Performance met the contract requirements - Confidence “M” = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory - No Confidence “U” = Unsatisfactory = Performance was poor and/or did not satisfy contract requirements – No

Confidence

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. – Unknown Confidence

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

Q1. To what extent did the contractor comply with overall contract requirements?

E G S M U

Q2. How successful was the Contractor in filling all requirements? E G S M U

Q3. How would you rate the quality of the Physicians provided by this Contractor in terms of technical competence, reliability, and demeanor with patients and staff.

E G S M U

Q4. To what extent was the Contractor able to meet unexpected and short notice changes and/or requirements (e.g. unexpected shift vacancies, training requirements).

E G S M U

Q5. How would you rate the Contractor’s administrative staff as pertains to communication with your organization’s key personnel, their ability to complete credentialing and privileging, billing and invoicing processes, and overall contract management?

E G S 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

4. Thank you for your time. Please return completed questionnaire to Patricia Toliver, Contracting Specialist for this acquisition, at patricia.toliver@va.gov .

mailto:patricia.toliver@va.gov