D.5 Past Performance Questionnaire.pdf

ATTACHMENT D.5 PAST PERFORMANCE QUESTIONNAIRE

Reference RFQ: 36C25025Q0020 – Perfusionist Services

INSTRUCTIONS: The Network Contracting Office (NCO) 10 is considering the Company (Quoter) listed below for award of a Department of Veterans Affairs Contract. You have been identified as a previous/current purchaser of the Company’s services, and your assistance with establishing the performance history for the Company is requested. Please note that your comments are considered source selection information and will not be shared in any way with the Company or any party outside the Department of Veterans Affairs.

This survey should be completed by an evaluator with sufficient knowledge of the Company’s performance and then sent directly to the Contract Specialist via email at Karen.Williams4@va.gov no later than the closing date and time of the solicitation. The Company (Quoter) should provide this information to you.

Information of the Company (Quoter) being evaluated:

Company Name: ________________________________________

Company Address: ________________________________________

Information of the Evaluator:

Evaluator Name and Title: _________________________________________

Company Name: _________________________________________

Phone Number: _________________________________________

Address: _________________________________________

Information of the Contract:

Contract Number: _________________________________________

Dollar Value: _________________________________________

Dates of Performance: _________________________________________

Brief Description of Work:______________________________________________________________ mailto:Karen.Williams4@va.gov

OVERALL RATING FOR THIS COMPANY IS:________________________________

Please provide supporting comments for each question below explaining the reasoning the particular rating was given.

“O” =Outstanding = Performance greatly exceeded the contract requirements “A” =Above Average = Performance exceeded the contract requirements “S” = Satisfactory = Performance met the contract requirements “M” = Marginal = Performance met the minimum contract requirements, but some material aspects of the contractor’s performance were less than satisfactory “U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements Please rate and provide information and detailed comments for the following: Circle one

1. To what extent did the contractor comply with contract requirements? O A S M U

2. If reports were required, were they submitted timely per the contract requirements? O A S M U

3. To what extent did the contractor demonstrate ability to hire, maintain, or replace if necessary qualified key personnel during contract period?

O A S M U

4. To what extent was contractor able to meet the performance schedule? O A S M U

5. To what extent was the contractor responsive to technical directions? O A S M U

6. To what extent was contractor flexible in responding to changing needs? O A S M U

7. To what extent did contractor notify you of problems or potential problems? O A S M U

8. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, please explain

Yes No

9. Would you award another contract to the party being evaluated? If no, please explain: Yes No

10. Was the customer satisfied with the services provided? If no, please explain:

Yes No

Additional Comments:

Signature of Evaluator:_____________________________________________

Date:____________