D.5 PAST PERFORMANCE SURVEY.docx
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- Solicitation number
- 36C24624R0024
About this file
This past performance survey template is used to evaluate prospective medical service providers for a mobile Positron Emission Tomography/Computerized Tomography (PET/CT) services contract across three Department of Veterans Affairs medical centers. The contractor will provide all labor, materials, equipment, maintenance, repairs, specialized staff, required supplies, medications, and drugs to perform PET/CT services at Charles George (Asheville) VAMC, Hampton VAMC, and Salem VAMC in accordance with the performance work statement. The base period of performance is April 1, 2024 through March 31, 2025 with four optional one-year extensions. Evaluators will rate satisfaction with overall performance, issue response and correction, professionalism, and on-time service delivery on a scale of excellent, very good, acceptable, and unacceptable.
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36C24624R0024
D.3 PAST PERFORMANCE SURVEY
Past Performance Questionnaire 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 to RFP closing date to David.Smith78@va.gov Name of Contract Specialist: David E. Smith 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. Evaluator’s Title:
4. Evaluator’s Phone #:
5. Evaluator’s Email:
6. Start Date of Contract
SOURCE SELECTION INFORMATION
SEE FAR 2.101 and 3.104
FOR OFFICIAL USE ONLY
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. Is this Mobile PET SCAN services? | |_| YES | |_| | NO | |
| Was full range medical service capability required? |_| | YES | |_| | NO | |
| Did contractor meet established performance standards? | |_| | YES | |_| | NO |
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.
FOR OFFICIAL USE ONLY
SECTION IV - Closing Comments
Pertinent comments regarding past performance of this company:
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