D.31 Past Performance Questionnaire.docx

Past Performance Questionnaire

1. The Contractor identified below has requested that your organization complete a past performance questionnaire on their behalf. This questionnaire will be used by the Contracting Officer to assess the likelihood that the Contractor will perform successfully on an impending requirement for the New Mexico VA Health Care System (NMVAHCS). Your prompt completion and return of this questionnaire is greatly appreciated.

2. Background. The NMVAHCS requires Community Based Outpatient Clinic (CBOC) services providing Primary Care (PC), space and administrative support to veterans.

CONTRACTOR NAME _________________________

REFERENCED RFP # 36C25821R0016___________

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

Dates of Performance (if current include expiration date) Contract Number Evaluated: _______________________

Dollar Amount of Contract.$ ___________________ Sub-Contractor Contractor Performed: Prime Contractor Name of Government Agency or Organization:

Name of Person Completing Response: Title: Phone E-mail:

Address of Record:

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

Q1. Did the contractor provide CBOC services to your agency / organization?

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

5. Evaluate the performance using only the following ratings without variation. Provide additional information in the appropriate block or in the remarks section of this form.

H = High Confidence Performance record provides virtually no doubt that the Offeror successfully performed the required effort.

C= Confidence Performance record indicates the Offeror was able to successfully perform the required Effort.

N= No Confidence Performance record provides extreme doubt that the Offeror successfully performed the required effort.

U= Unknown Confidence Offeror has no relevant performance record

Write in “not applicable” or “neutral” if unable to rate a certain question. Please provide a short summary explanation of rating.

Rate and provide information/comments for the following:

Rating Check one

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

H___

C___

N___

U___

Q2. How successful was the Contractor in filling all staffing and clinical service requirements?

H___

C___

N___

U___

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

H___

C___

N___

U___

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

H___

C___

N___

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?

H___

C___

N___

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. Comments regarding any known performance deemed unacceptable to the customer, or not in accordance with the contract terms and conditions:

Printed Name & Signature of Evaluator

Date

6. Please return completed questionnaire to Contract Specialist at: Arcelia.Medina@va.gov