D.5 - Past Performance Survey-Questionnaire.docx
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- Solicitation number
- 36C24926R0007
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This is a Past Performance Survey-Questionnaire template for evaluating contractor performance on teleradiology services contracts for the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Veterans Integrated Service Network (VISN) 9. The survey is designed to be completed by evaluators who have direct experience with the contractor's service delivery and must be submitted directly to Ramona Bonness at ramona.bonness@va.gov by February 27, 2026 at 10:00 AM Central Time. Surveys submitted by offerors themselves will not be accepted.
The questionnaire assesses contractor performance across fourteen evaluation criteria using a five-point rating scale (Outstanding, Above Average, Satisfactory, Marginal, and Unacceptable) and yes/no questions. Key evaluation areas include compliance with contract requirements, timeliness in filling medical positions, contract management effectiveness, work quality, flexibility in responding to changing needs, reliability, responsiveness to technical direction, problem notification practices, invoice accuracy, and customer professionalism. The form also requires evaluators to disclose whether any cure notices, show cause letters, suspension of payment, or termination actions were issued, and whether the evaluator would award another contract to the contractor. Evaluators must provide detailed remarks for any ratings of Marginal or Unacceptable performance, and the form requires the evaluator's full name, position, company/organization information, and email address for verification and follow-up purposes.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24926R0007 0004.docx | DOCX document | |
| 36C24926R0007 0003.docx | DOCX document | |
| 36C24926R0007 0002.docx | DOCX document | |
| D.3 - CONFLICT OF INTEREST CERTIFICATION STATEMENTR1.pdf | ||
| 36C24926R0007 0001.docx | DOCX document | |
| RFQ 36C24926R0007 Questions and Answers.docx | DOCX document | |
| D.5 - Past Performance Survey-QuestionnaireR1.docx | DOCX document | |
| D.3 - CONFLICT OF INTEREST CERTIFICATION STATEMENT.pdf | ||
| D.2 - CONTRACTOR CERTIFICATION IMMIGRATION AND NATIONALITY ACT OF 1952 AS AMENDED.pdf | ||
| D.4 - VHA Teleradiology Handbook.docx | DOCX document | |
| D.1 QASP TELRADIOLOGY CONTRACTORS.docx | DOCX document | |
| 36C24926R0007.docx | DOCX document |
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Text version
ATTACHMENT D:5 TELERADIOLOGY SERVICES 36C24926D0026
36C24926R0007 – VISN 9 Tele-Radiology Services Attachment D.5 – Past Performance Survey
Past Performance Survey
Please have evaluator complete and email directly to Ramona Bonness at ramona.bonness@va.gov by February 27, 2026 at 10:00AM CT. Surveys will not be accepted if sent by the Offeror.
Name of Offeror Evaluated:
Contract Number:
Evaluator’s Full Name:
Evaluator’s Position held or function in relation to project:
Evaluator’s Company/Organization Name, Address and Phone number:
Evaluator’s email address:
Reference Instructions: Your comments would be appreciated regarding this vendor’s past performance.
Please evaluate the Past Performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, provide additional information in the appropriate block or in the remarks section of this form.
O = Outstanding Performance greatly exceeded contract requirements
A = Above Average Performance exceeded contract requirements
S = Satisfactory Performance met 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
Describe exactly what type of Outpatient Clinic Services or similar service(s) were provided to your company/organization?
Length of the Service (Provide dates):
| Rate the following questions if the company provided temporary medical staffing or similar services. Provide information/comments in the Remarks Section below. |
| Highlight One |
Q1. To what extent did the Contractor comply with contract requirements?
O A S M U
Q2. How timely was the Contractor’s performance when filling medical positions needed?
O A S M U
Q3. Rate the effectiveness of the Contractor’s management of the contract?
O A S M U
Q4. Quality Control: Rate the overall quality of Contractor’s work.
O A S M U
Q5. What extent was Contractor flexible in responding to changing needs?
O A S M U
Q6. To what extent was the Contractor reliable?
O A S M U
Q7. To what extent was the Contractor responsive to technical directions?
O A S M U
Q8. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, explain on the following page.
Yes No
Q9. Would you award another contract to this Contractor? If no, explain on the following page.
Yes No
Q10. Was the customer satisfied with the service provided? If no, explain on the following page.
Yes No
Q11. To what extent did Contractor notify you of problems of potential issues?
O A S M U
Q12. Did the Contractor submit accurate invoices during the performance period?
Yes No
| Q13. Was the Contractor professional and courteous in its interaction with you? |
| Yes No |
Q14. Did the Contractor respond promptly to requests?
Yes No
Past Performance Survey – Remarks Section
Evaluator’s Additional Remarks regarding services:
Signature of Evaluator:
Print Name of Evaluator:
File details come from the government source that posted it. Updated .