D.5 Past Performance Questionnaire.docx
DOCX document 16 KB Posted
- Attached to
- G004-- HCHV SOLICITATION 589, 589A5, 589A6
- Solicitation number
- 36C25520Q0404_1
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Past Performance – Government Business – last 3 years
| Offeror Name: | CNH Facility Name: |
| Facility City: | Facility County: |
1. Indicate any (up to 3) Federal Contracts, Agreements or similar patient placement arrangement held by, or entered into by the offeror’s nursing facility in the last 3 years, even if under different ownership than current ownership that involved the same or similar types of services described in this Request for Proposal, indicating:
- The Federal office or VA Medical Center locations:
- The contract, agreement or arrangement information (number, title, other identifier), period of services:
- The Contracting Officer or similar Representative contact information (name, phone, fax, address, e-mail):
Past Performance – Non-Government Business – last 3 years
1. If NO Federal Contract, Agreement or similar patient placement arrangement has been held in the past, please indicate Non-Government Agency-related past performance information substantially the same as requested above within the past 3 years.
- Non-Government customers (e.g. hospital, physician group, etc.) Note – do not provide individual patient references:
- Non-Government customer arrangement information (number, title, other identifier) or period of services:
- The officials responsible for the arrangement(s) contact information (name, phone, fax, address, e-mail):
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