D19. PAST PERFORMANCE QUESTIONNAIRE.docx

ATTACHMENT D19 – Bogalusa CBOC

PAST PERFORMANCE QUESTIONNAIRE

1. The Contractor identified below has requested that you complete a past performance questionnaire on their behalf. This questionnaire will be used by the Contracting Officer, Toni A. Clendenen, to assess the likelihood that the Contractor will perform successfully on an impending requirement for a Community Based Outpatient Clinic (CBOC) for the beneficiaries of Southeast Louisiana Veterans Health care System. Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME _________________________________________

REFERENCED CONTRACT # _________________________________________

2. Background. The Southeast Louisiana Veterans Health Care System (SLVHCS), the parent facility, requires CBOC services providing Primary Care and Mental Health care. The clinic shall be located in a private hospital, office or clinic environment in Bogalusa, Louisiana. This clinic will service Veterans throughout the Washington and Annunciation Parish catchment area. (RFP number 36C25621R0041)

3. GENERAL INFORMATION: (Completed by Reference of Contractor being evaluated)

Name of Government or Commercial Organization:______________________________ Address:_________________________________ Contract Number:______________________________

Brief Description of services (used for determination of relevancy): _____________________________________________________________________________________

Contractor Performed as: |_|Prime Contractor |_|Sub-Contractor Dates of Performance (if current include expiration):____________________________ (used for determination of recency)

Total Cost of Contract:__________________Award/Incentive/Deduction_____________ Any terminations for cause or default? Circle YES or NO If yes, brief explanation:___________________________ Point Of Contact/COR:____________________________ Title:___________________________________ Telephone Number:____________________________ Point of Contact’s email address:______________________

4. Please answer the following questions pertaining to the relevancy of the services provided to you as compared to the description in paragraph 2.

Q1. Did the contractor provide both Primary care and Mental Health Services (Y/N)?____________

Q2. If Contractor did not provide both of the above; please provide a short description of the type of services provided.

Q3. Did the contractor provide any additional services (Y/N)?________________ If so, what types?

5. Please use the below matrix to answer questions relating to performance using the following template.

Please evaluate the past performance using only the following ratings without variation. If the rating is Excellent, Good, Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form.

“E” = Excellent = Very High Confidence and Performance greatly exceeded the contract requirements.

“G” = Good = High Confidence and Performance exceeded the contract requirements.

“S” = Satisfactory = Confidence and Performance met the contract requirements.

“M” = Marginal = Low Confidence and Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory.

“U” = Unsatisfactory = NO Confidence and Performance was poor and/or did not satisfy contract requirements.

Please write in “not applicable” or “neutral” if unable to rate a certain question. For any E, G, M, or U rating please provide a short summary explanation of rating.

Q1. To what extent did the contractor comply with overall contract requirements?

E G S M U

Q2. How successful was the Contractor in filling all requirements?

E G S M U

Q3. How would you rate the quality of the Physicians and other staff provided by this Contractor in terms of technical competence, reliability, and demeanor with patients and staff?

E G S M U

Q5. How would you rate the Contractor’s administrative staff as pertains to communication with your organization’s key personnel, their ability to complete credentialing and privileging, billing and invoicing processes, and overall contract management and professionalism?

E G S M U

Q6. Did you issue any cure notices, show cause letters, or suspension of payment? If yes, please explain.

Yes No

Q7. Would you award another contract to the Contractor being evaluated? If no, please explain:

Yes No

Additional Comments pertaining to contractor performance in particular to Quality of Service, Timeliness of Performance, and Business Relations:

Printed Name & Signature of Evaluator

Date

6. Thank you for your time! Rater shall send the completed questionnaire DIRECTLY to Toni A. Clendenen, Contracting Officer for this acquisition, at toni.clendenen@va.gov no later than the due date from Block 11 of SF 1449 __________________(Offeror to insert date prior to sending to reference). Completed questionnaires provided by offeror will not be accepted. Title email to include RFP No. 30C25621R0041: Past Performance (NAME OF COMPANY BEING RATED) Questions may be addressed to Toni A. Clendenen at toni.clendenen@va.gov.