D.6 Past Performance Questionnaire.pdf
PDF 166 KB Posted
- Attached to
- Q509--589A7 | WI | NEPHROLOGY PHYSICIAN SERVICES BASE + 4OY | CO MICHAEL CARSON (VA-25-00091098)
- Solicitation number
- 36C25527Q0002_1
About this file
This document is a Past Performance Questionnaire template for evaluating vendors responding to Request for Quotation (RFQ) 36C25527Q0002 for Nephrology Physician Services. The questionnaire is to be completed by references or past clients of the vendor being evaluated and submitted to michael.carson1@va.gov by August 26, 2026. The form requests organization information including the point of contact's name, email, phone, and title, as well as a brief description of services provided and period of performance.
The questionnaire requests ratings across four key performance areas: overall quality of contract performance, vendor's ability to provide licensed and qualified candidates, vendor's ability to provide the requested amount of services without lapse of services, and contracted personnel turnover rate. Respondents must assign one of five ratings (exceptional, very good, satisfactory, marginal, or unsatisfactory) to each area, with comments required for anything rated above or below satisfactory. The form also includes a section for any other pertinent information and requires the respondent's signature and name/title. This is a template document designed to gather reference information to support the VA's evaluation of bidders for nephrology physician staffing services.
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Text version
D.7 PAST PERFORMANCE QUESTIONNAIRE
Reference Request For Quotation (RFQ) 36C25527Q0002; Nephrology Physician Services
Vendor being evaluated:_______________________________________________________
Please provide your candid responses. The information that you provide will be used in the awarding of a federal contract. Therefore, it is important that your information be as factual, accurate and complete as possible to preclude the need for follow-up by the evaluators. If you do not have knowledge of or experience with the company in question, please forward this Questionnaire to the person who does. Please complete this document and email it directly to michael.carson1@va.gov by:
Thank you.
ORGANIZATION INFORMATION
ORGANIZATION NAME AND
ADDRESS
POINT OF CONTACT
Name:
Email:
Phone:
Title:
BRIEF DESCRIPTION OF SERVICES PROVIDED & PERIOD OF PERFORMANCE
Please provide ratings (exceptional, very good, satisfactory, marginal, or unsatisfactory) in the following areas and add comments for anything above or below Satisfactory:
1. Overall Quality of contract performance:
Comments:
2. Vendor’s overall ability to provide licensed and qualified candidates:
Comments:
3. Vendor’s ability to provide the requested amount of services without lapse of services:
Comments:
4. Contracted personnel turnover rate:
Comments:
Any other pertinent information:
Signature:__________________________________________________________ Name/Title:_________________________________________________________
| PAST PERFORMANCE REFERENCES |
| D.6 Past Performance Questionnaire_PG comments.pdf |
| PAST PERFORMANCE QUESTIONNAIRE |
| Services: |
| DateTime: August 26, 2026 |
| ORGANIZATION NAME AND ADDRESSRow1: |
| Name: |
| Email: |
| Phone: |
| Title: |
| BRIEF DESCRIPTION OF SERVICES PROVIDED PERIOD OF PERFORMANCERow1: |
| Comments1: |
| Rating_1: [ ] |
| Rating_2: [ ] |
| Comments2: |
| Rating_3: [ ] |
| Comments3: |
| Rating_4: [ ] |
| Comments4: |
| FinalComments: |
| NameTitle: |
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