D.5 PAST PERFORMANCE QUESTIONNAIRE.docx

PAST PERFORMANCE QUESTIONNAIRE

TITLE: VISN 2 South Medical Gas

SOLICITATION NUMBER: 36C24222R0100

OFFER / QUESTIONNAIRE DUE DATE: _______________________

SECTION I: OFFERORS: COMPLETE requested information (Section I) and PROVIDE the questionnaire to the appropriate Respondent for each source of Past Performance Information mentioned in your Offer. The Respondent must have significant familiarity with the selected contract or subcontract to provide informed answers and comments about various aspects of the past performance.

NAME OF OFFEROR:

NAME OF PAST PERFORMANCE REFERENCE:

PAST PERFORMANCE CONTRACT NUMBER & DATES OF SERVICE:

DESCRIPTION OF SERVICE:

TOTAL AWARD PRICE:

SECTION II: RESPONDENT(S): COMPLETE the requested information (Section II) concerning the past performance of the above named Offeror relative to the referenced contract effort. For Box selections (|_|), double-click the box and select “Checked” for Default value.

NAME OF RESPONDENT:

TITLE/POSITION:

SIGNATURE:

(A) QUALITY OF SERVICE: For each section, please respond as it pertained to your contract.

1. Describe any issues with manufacturer licensing, permits, certifications or registrations required by the FDA and the states in which this contract was/is performed.

2. Describe any issues between the offeror and manufacturer with a reseller agreement involving reselling the medical gases and renting the medical gas cylinders.

3. Describe any safety incidents involving medical gases and/or cylinders.

4. Describe any delivery issues, whether standard or emergency orders.

5. Describe any supply chain issues in the last two years and specify the gases affected.

6. Describe any cylinder inventory audit issues.

Based on the responses above, would you rate Contractor’s performance as:

|_| Above Satisfactory |_| Satisfactory |_| Unsatisfactory (please enter specific comments if Above Satisfactory or Unsatisfactory)

Overall Rating Comments:

(B) MANAGEMENT AND BUSINESS RELATIONS

Describe any negative/adverse issues involving Key Personnel.

Was contract Management efficient and responsive?

|_| Always |_| Most of the time |_| Sometimes |_| Never

Did the Contractor exhibit effective communication(s)?

|_| Always |_| Most of the time |_| Sometimes |_| Never

Did the Contractor exhibit reasonable and cooperative behavior?

|_| Always |_| Most of the time |_| Sometimes |_| Never

Was the Contractor flexible?

|_| Always |_| Most of the time |_| Sometimes |_| Never

Did the Contractor recommend effective solutions to problems?

|_| Always |_| Most of the time |_| Sometimes |_| Never

Did the Contractor exhibit a business-like concern for the interests of your Agency or Business?

|_| Always |_| Most of the time |_| Sometimes |_| Never

How would you generally rate the Contractor in business relations?

|_| Outstanding |_| Good |_| Acceptable |_| Unacceptable

Enter Comments here for the above questions:

(C) CUSTOMER SATISFACTION

1. How would you rate the contractor based on Customer (end-user) satisfaction?

|_| Outstanding |_| Good |_| Acceptable |_| Unacceptable

2. Would you select this firm again? |_| Yes |_| No

Comments:

End of Section II SECTION III: COMPLETED FORM MUST BE RETURNED TO THE VA CONTRACTING OFFICE PRIOR TO THE DUE DATE FOR RECEIPT OF PROPOSALS. THE OFFEROR MAY SUBMIT THE COMPLETED QUESTIONNAIRE ALONG WITH HIS/HER PROPOSAL; OR, THE RESPONDENT PROVIDING THE PERFORMANCE INFORMATION HEREIN MAY FORWARD THE COMPLETED FORM DIRECTLY TO THE CONTRACTING OFFICE, IF PREFERRED.

IN ALL CASES, THE COMPLETED PAST PERFORMANCE REFERENCES MUST REACH THE CONTRACTING OFFICE BY THE DATE AND TIME OFFERS ARE DUE. THE GOVERNMENT BEARS NO RESPONSIBILITY TO ASSURE QUESTIONNAIRES ARE PROPERLY RECEIVED.

POC: Aleta Jennette Contracting Officer VA NCO 02 (Montrose, NY) Phone: (914) 737-4400 x202068 Email (preferred): Aleta.Jennette@va.gov