D.5 Past Performance Questionnaire.docx

Past Performance – Government Business – last 3 years

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):