D.4 PAST PERFORMANCE QUESTIONNAIRE.docx

PAST PERFORMANCE QUESTIONNAIRE

PART 1 (TO BE COMPLETED BY THE OFFEROR)

Provide the following information requested in this format for each of the projects/contracts being described. Projects may be on going or have been completed within five (5) years prior to the solicitation issue date. Provide accurate information on the contracts you identify. The form may be re-typed or copied into a new solicitation enclosure; however, all questions must be answered, and all information must be provided.

Respondent Information for Solicitation: 36C24825Q0251 – Durable Medical Equipment VISN 8 Southern Zone

A. Contractor Name:

1. Point of Contact:

2. Title:

3. Email:

4. Phone:

B. Project/Contract Title:

C. Contract Specifics:

1. Contract Number:

2. Total Contract Value:

3. Period of Performance:

4. Number of Vehicles providing services:

5. Description of Services provided:

Authorization is hereby granted to provide the information requested in this questionnaire to NCO 8, Bay Pines, Florida.

(Signature)

(Name & Title of Authorizing Official) (Date)

PART 2 (TO BE COMPLETED BY THE ASSESSOR)

The intent of this form is to evaluate the Offeror’s past performance with your company. Information provided is considered sensitive; therefore, the release of individual’s names providing reference information about Offeror’s past performance will not be disclosed and will remain with the contracting office.

This survey should be completed by an assessor with sufficient familiarity of the Offeror’s performance and returned by the assessor no later than the offer due date and time of the solicitation to jessica.kiser@va.gov. Please reference “36C24825Q0251 - Past Performance/Company Name” in the subject field of your email.

a. What was the timeliness of Service/Turnaround Time for delivery (in days) following vendor receipt of the prescription order?

b. Were there any Product Quality / Repair frequencies / Incidence of errors?

c. Volume - Was the vendor able to manage the volume within the established timeframes for delivery in the contract?

d. Type/Number of Billing Errors? Were invoices provided on paper or was an electronic process available/used?

e. Respect for HIPAA/Information Security – Patients / Credit Card Information. Does the vendor have the ability to encrypt patient/billing information?

f. Were the vendor effective in Infection Control Plan/Practices?

g. Did contractor maintain contract pricing agreements?

h. What corrective actions (if any) were taken to resolve problems on past or existing contracts and trends in performance.

i. Did the vendor provide overall development, access, use of company electronic patient records?

j. Were there any instances of non-performance, no shows due to labor/staff delays? If yes did the company offer any alternatives

k. Provide any feedback on areas were company can improve its service?

l. Would you award contract or purchase order to this company?

Signature of Assessor / Evaluator Date

Name:

Title:

Email: