D.6 Past Performance References.pdf

PAST PERFORMANCE REFERENCES

Reference Request For Proposal (RFP) 36C25524R0061; Radiation Oncology Physician

Services

Offerer:_______________________________________________________________________

Provide three (3) references with either Radiation Oncologists or similar complexity physicians within the last 24 months.

Thank you.

REFERENCE 1 INFORMATION

ORGANIZATION NAME AND

ADDRESS

POINT OF CONTACT

Name:

Email:

Phone:

Title:

BRIEF DESCRIPTION OF SERVICES PROVIDED & PERIOD OF PERFORMANCE

REFERENCE 2 INFORMATION

ORGANIZATION NAME AND

ADDRESS

POINT OF CONTACT

Name:

Email:

Phone:

Title:

BRIEF DESCRIPTION OF SERVICES PROVIDED & PERIOD OF PERFORMANCE

REFERENCE 3 INFORMATION

ORGANIZATION NAME AND

ADDRESS

POINT OF CONTACT

Name:

Email:

Phone:

PAST PERFORMANCE QUESTIONNAIRE

Reference Request For Proposal (RFP) 36C25524R0061; Radiation Oncology 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:

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:

3. Vendor’s ability to provide the requested amount of services without lapse of services:

4. Contracted personnel turnover rate:

5. Vendor’s efforts to provide locally sourced candidates:

Any other pertinent information:

Signature:__________________________________________________________ Name/Title:_________________________________________________________