D.4 - Past Performance Survey.docx
DOCX document 25 KB Posted
- Attached to
- Q502--LOCUM - Perfusion Services - 626 POP: 6/1/26 - 5/31/27 UCD 5/31/2031 MSO-2026-COM-0021 BOC 2579
- Solicitation number
- 36C24926R0040
About this file
This is a Past Performance Survey form used by the Department of Veterans Affairs to evaluate contractor references for the Perfusionist Services contract (Solicitation Number 36C24926R0040). The survey is designed to be completed by past clients or references of offerors bidding on a VA contract for onsite and on-call Perfusionist services at Tennessee Valley Healthcare System in Nashville, Tennessee, with a base year plus four option years commencing June 1, 2026.
The survey requests evaluators to rate contractor performance across six key criteria using a five-point scale (Superior, Very Good, Fully Acceptable, Marginally Acceptable, or Unacceptable): compliance with requirements and expectations, knowledge and expertise in providing cryoablation services, quality of technicians, accessibility and timeliness of personnel response, ease of scheduling processes, and patient privacy protection. The form also includes a yes/no question regarding whether the evaluator would award another contract to the firm and provides space for additional remarks. Completed surveys must be submitted to Samantha Shackelford at samantha.shackelford@va.gov no later than April 16, 2026 at 5:00 p.m. EST, and must include the evaluator's name, title, contact information, and signature. The survey is marked as Source Selection Sensitive, with reference provider names to be kept confidential.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24926R0040.docx | DOCX document | |
| D.3 - Organizational Conflict of Interest.docx | DOCX document | |
| D.1 - Quality Assurance Surveillance Plan.docx | DOCX document | |
| D.5 - Contractor Rules of Behavior.pdf | ||
| D.2 - Contractor Certification of Immigration.pdf |
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Text version
36C24926R0040 - ATTACHMENT D.4 PAST PERFORMANCE SURVEY
AS-NEEDED PERFUSIONIST SERVICES
REFERENCE INSTRUCTIONS: The Department of Veterans Affairs is seeking offerors for award of a VA contract for onsite and on-call Perfusionist services for a base year plus four option years. You have been identified as a reference and your comments would be appreciated. Your comments are considered Source Selection Sensitive; therefore, you are advised that the release of the names of individuals providing reference information about Offeror’s past performance is prohibited. Survey should be completed by evaluator and submitted no later than April 16, 2026 @ 5:00 p.m. EST via email directly to samantha.shackelford@va.gov.
NOTE: Incomplete or unsigned surveys will not be considered.
Company being evaluated:_______________________________________________ Period of Performance:__ What was the average monthly volume of the services provided? (Number of cases per month? Average number of hours per case?) __ ____________________________________ Name and title/position of evaluator:
Contact telephone number:
Contact e-mail address:
Please evaluate the past performance using only the following ratings without variation. If the rating is other than Fully Acceptable, please provide additional information in the appropriate block or in the remarks section of this form.
S = Superior Performance
V = Very Good with very few issues
F = Fully Acceptable/Good
M = Marginally Acceptable
U = Unacceptable Performance
| Please rate and provide information/comments for the following: |
| Circle/indicate selection |
| Q1. Rate how well the contractor complies with requirements and/or expectations? |
| S V F M U |
| Q2. Rate contractor’s knowledge and expertise in providing cryoablation services. |
| S V F M U |
| Q3. Rate this contractor’s technicians. |
| S V F M U |
| Q4. Rate the level of access to the contractor’s personnel. (i.e. Did they respond in a timely manner? Did they meet the requirements of being available and responding as according to the contract?) |
| S V F M U |
| Q5. Rate overall ease of contractor’s scheduling process. |
| S V F M U |
| Q6. Rate how well contractor protects the privacy of patients. |
| S V F M U |
Q9. Would you award another contract to the firm being evaluated? If no, please explain:
Yes No
Additional Remarks: Please use this space to indicate anything else you would like to say about the contractor being referenced or to list anything you especially liked or disliked about this contractor:
| Signature of Evaluator |
| Date |
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