D.5 PAST PERFORMANCE SURVEY.pdf

D.4 PAST PERFORMANCE SURVEY

36C25720R0099 – Registered Nursing Staffing Services Contract

Past Performance Questionnaire: The past performance questionnaire must be independently completed by the offeror’s client references. Offerors are responsible for ensuring that their client references complete this questionnaire and submit it via email directly to Matthew Clements at Matthew.Clements2@va.gov. 36C25720R0099 – Registered Nursing Staffing Services Contract Contract in the subject line, NO LATER THAN THE DUE DATE AND TIME OF THE

SOLICITATION.

PAST PERFORMANCE QUESTIONNAIRE

1. Contractor Name:

Role on Project: (Prime/Subcontractor):

2. Contract Number:

3. Contractor Address: 4. Contract Type:

____Firm Fixed Price

____T&M/LH

____Cost Reimbursement ____Other (Please Specify)______________

5. Agency/Company Name: 6. Agency/Company POC/Phone/Email:

7. Period of Performance: 8. Dollar Amount at Award: $______________ Annual Amount: $_____________________ Total Dollar Value with Mods:$___________

9. Title of Contract:

10. Description of Contract Service/Scope of Contract:

11. Complexity of Work: Difficult: ____ Moderate: ____ Routine: _____ mailto:Matthew.Clements2@va.gov

NOTE: Please use adjectival ratings for items A – C and E – G below.

Item D uses a numerical ratings scale 1 to 5. Ratings guidelines are provided on pages 4 & 5.

12. Subject Area 13. Comments (Attach additional sheets, if necessary.) 14. Rating

A. Quality of Work PLEASE PROVIDE COMMENTS, PARTICULARLY IF

RATING ASSIGNED IS EXCEPTIONAL OR

UNSATIFACTORY

B. Personnel – Knowledge, Skills and Abilities

PLEASE PROVIDE COMMENTS, PARTICULARLY IF

RATING ASSIGNED IS EXCEPTIONAL OR

UNSATIFACTORY

C. Cost/Budget Control PLEASE PROVIDE COMMENTS, PARTICULARLY IF

RATING ASSIGNED IS EXCEPTIONAL OR

UNSATIFACTORY

D. Customer Satisfaction PLEASE PROVIDE COMMENTS, PARTICULARLY IF RATING ASSIGNED IS “5” (highest) OR “1” (lowest)

(1 – 5)

E. Timeliness of Performance/ Deliverables

PLEASE PROVIDE COMMENTS, PARTICULARLY IF

RATING ASSIGNED IS EXCEPTIONAL OR

UNSATIFACTORY

F. Business Relations PLEASE PROVIDE COMMENTS, PARTICULARLY IF

RATING ASSIGNED IS EXCEPTIONAL OR

UNSATIFACTORY

G. Overall Performance PLEASE PROVIDE COMMENTS, PARTICULARLY IF

ASSIGNED RATING IS EXCEPTIONAL OR

UNSATISFACTORY

15. Would you select this contractor again? Please explain.

(Attach additional sheet if necessary.)

16. Name and title of individual who completed this questionnaire:

17. Date:

Past Performance Rating Guidelines

Summarize contractor performance in each of the rating areas. Assign each area a rating of Unsatisfactory, Marginal, Satisfactory, Very Good, and Exceptional. Use the following instructions as guidance in making these evaluations. Please use the comments area on the preceding form to justify the rating given.

Ratings Quality of Work/ Personnel Capabilities

-Compliance w/contract requirements -Accuracy of reports -Appropriateness of personnel -Technical excellence

Cost/Budget Control

-Within budget -Current, accurate, complete billings -Relationship of negotiated costs to actual -Cost efficiencies -Change orders issued

Customer Satisfaction

Customer Satisfaction is a measure of how products and services supplied by a company meet or surpass customer expectation.

On a scale of 1-5 (5 being the highest) please rate and describe your level of satisfaction with the contractor’s performance.

5 - Very satisfied

4 - Somewhat satisfied

3 - Neither satisfied nor dissatisfied

2 -Somewhat dissatisfied

1 - Very dissatisfied

Timeliness of Services/Deliverab les

-Met interim milestones -Reliable -Responsive to technical direction -Completed on time

Business Relations

-Effective management -Business like correspondence -Responsive to contract requirements -Prompt notification of problems -Reasonable/ cooperative -Flexible -Pro-active

Unsatisfactory Nonconformance's are comprising the achievement of contract requirements

Cost issues are comprising performance

Delays are compromising achievement of contract requirements

Response is not effective

Marginal Nonconformance's require major agency resources to ensure achievement of contract requirements

Cost issues require major agency resources to ensure achievement of contract requirements

Delays require major agency resources to ensure achievement of contract requirements

Response is marginally effective

Satisfactory Nonconformance's do not impact achievement of contract requirements

Cost issues do not impact achievement of contract requirements

Delays do not impact achievement of contract requirements

Response is usually effective

Very Good There are no quality problems/issues, and the contractor has substantially exceeded the contract performance requirements without commensurate additional costs to the Government

There are no cost management issues and the Contractor has exceeded the contract requirements, achieving cost savings to the Government.

There are no delays Response to inquiries and/or technical, service, administrative issues are effective.

Exceptional The contractor has demonstrated an exceptional performance level that was significantly in excess of anticipated achievements and is commendable as an example for others. It is expected that this rating will be used in those rare circumstances where contractor performance clearly exceeds the performance levels described as "Exceptional".

The contractor has demonstrated an exceptional performance. It is expected that this rating will be used in those rare circumstances where the contractor achieved cost savings and performance clearly exceeds the performance levels described as "Exceptional".

The contractor has demonstrated an exceptional performance level.

It is expected that this rating will be used in those rare circumstances where contractor performance clearly exceeds the performance levels described as "Exceptional".

The contractor has demonstrated an exceptional performance level.

It is expected that this rating will be used in those rare circumstances where contractor performance clearly exceeds the performance levels described as "Exceptional".