D.5 PAST PERFORMANCE QUESTIONNAIRE PERFORMANCE SURVEY 02.docx
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- 36C24221Q0278
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36C24221Q0240- Buffalo VA Medical Center Mobile Surgical Services
SOURCE SELECTION INFORMATION
SEE FAR 2.101 and 3.104
FOR OFFICIAL USE ONLY
D.5 PAST PERFORMANCE SURVEY
This form is used to evaluate the past performance and experience of a prospective medical service provider company.
Completed form must be e-mailed prior proposal closing date to Danelle.Wassink@va.gov.
SECTION I - Details of Company Being Evaluated
1. Company Name:
2. Service Provided:
3. Number and type of Personnel:
SECTION II - Details of Evaluator
1. Evaluator’s Company:
2. Evaluator’s Name:
3. Evaluators Title:
4. Evaluator’s Phone #:
5. Evaluator’s Email:
6. Start Date of Contract:
SECTION III - Customer Satisfaction/Quality of Service Questions Rate the company’s product and service performance using the scale indicated for each question:
| 1. | How would you rate satisfaction with the overall performance of this Company? |
| 3= Excellent 2= Very Good 1= Acceptable 0= Unacceptable | |
| |_|3 |_|2 |_|1 |_|0 |
| 2. | How would you rate the extent that the Company responded to and attempted to correct any concerns, issues, or problems that appeared during performance of your contract? |
| 3= Excellent 2= Very Good 1= Acceptable 0= Unacceptable | |
| |_|3 |_|2 |_|1 |_|0 |
| 3. | How would you rate the professionalism of the Company? |
| 3= Excellent 2= Very Good 1= Acceptable 0= Unacceptable | |
| |_|3 |_|2 |_|1 |_|0 |
| 4. | What percentage of time did the Company provide on time services in accordance with contract requirements? |
| 3= 90% of the time 2= 85-89% of the time | |
| 1= 80-84% of the time 0= <80% of the time | |
| |_|3 |_|2 |_|1 |_|0 |
| 5. | If given an opportunity, how likely is it you would conduct business with this Company again? |
| 3= Very Likely 2= Likely 0= Not Likely | |
| |_| 3 |_| 2 |_| 0 |
Please provide an explanation of all unacceptable ratings and make additional comments as applicable on all ratings in Section III.
SECTION IV – Service Performance Questions
Rate the company’s product and service performance using the scale indicated for each question
| 4 = Excellent |
| 3 = Very Good |
| 2 = Acceptable |
| 1 = Unacceptable |
| 0 = Not Applicable |
| 1. | How would you rate satisfaction with the overall performance of the services provided? |
| |_|4 |_|3 |_|2 |_|1 |_|0 |
| 2. | Overall User Satisfaction with service: |
| |_|4 |_|3 |_|2 |_|1 |_|0 |
| 3. | Overall User Satisfaction with continuity of service: |
| |_|4 |_|3 |_|2 |_|1 |_|0 |
| 4. | Was the Monthly/Daily Effectiveness Level Consistently Met? |
| |_| YES | |_| NO |
|_| Not Applicable
| 5. | Was this contract for low & high-watt Holmium laser services? | |_| YES |_| NO | |
| Was this contract for C02 laser services? | |_|YES |_| NO | ||
| Was this contract for Lithotripsy (ESWL) services? | |_|YES |_| NO | ||
| Did technicians demonstrate a high-level of competency? | |_|YES |_| NO | ||
| Did technicians complete & provide Laser Use Records promptly? |_|YES |_| NO |_| N/A | |||
| Did Contractor meet established performance standards? | |_|YES |_| NO | ||
| Was equipment maintenance provided regularly/ as indicated? | |_|YES |_| NO | ||
| Was the Contractor able to respond promptly to emergency cases? |_|YES |_| NO |_| N/A |
Please provide an explanation of all unacceptable ratings and make additional comments as applicable on all ratings in Section IV or give any other comments regarding your medical services.
SECTION IV - Closing Comments
Pertinent comments regarding past performance of this company:
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