Exhibit A - Past Performance Questionaire - 36C24121Q0385.docx

EXHIBIT A PACKAGE INFORMATION AND FORMS

Instructions to Offeror for sending Reference Questionnaire Forms: Prepare and send a reference questionnaire package for at least 2 projects of similar size, scope and complexity to the subject project completed in the last 5 years. For Government contracts, send to Contracting Officer or Technical Representative. For commercial references send to personnel with duties similar to those for Government contracts. It is your responsibility to follow-up and to encourage your references to send in their questionnaire. Completed Questionnaires should be remitted via email to the Contracting Officer identified in the RFQ and the RFQ number should be identified in the subject matter of the email. If you have multiple references at one location, send one cover letter and questionnaire for each contract you want a reference for. Your questionnaire package should contain the following.

1. Cover Letter (See SAMPLE) (Exhibit A1)

2. Respondent Info and Past Performance Sheet (Exhibit A) Offeror should put name in spaces indicated and ensure it is on every page for identification purposes

OFFEROR SHOULD PLACE THEIR NAME ON TOP OF EACH QUESTIONNAIRE PAGE!!!

OFFEROR SHOULD DELETE THESE INSTRUCTIONS BEFORE SENDING OUT QUESTIONNAIRES

EXHIBIT A1

SAMPLE TRANSMITTAL LETTER AND PAST PERFORMANCE EVALUATION QUESTIONNAIRE

Your Company Letterhead

Date: _________________ To: ______________________________________

We have listed your firm as a reference for the work we have performed for you as listed below. Our firm has submitted a quote for a project with VISN 1 in WRJ, VT. In accordance with Federal Acquisition Regulations (FAR), they will evaluate our firm's past performance. Your candid response to the attached questionnaire will assist the evaluation team in this process. We understand that you have a busy schedule and your participation in this evaluation is greatly appreciated. Please complete the enclosed questionnaire as thoroughly as possible. Space is provided for comments. Understand that while the responses to this questionnaire may be released to the offeror, FAR 15.306 (e)(4) prohibits the release of the names of the persons providing the responses. Complete confidentiality will be maintained. Only one response from each office is required.

Please send your completed questionnaire to the following address to arrive NOT LATER THAN April 30, 2021 at 4:00 pm. Do not return them to our company. PLEASE NOTE THAT EMAIL RESPONSE TO CLARK.CRANDALL@VA.GOV IS THE PERFERRED METHOD, SUBJECT LINE TO READ: PAST PERFORMANCE 36C24121Q0385.

If you have questions regarding the attached questionnaire, or require assistance, please contact Clark Crandall at clark.crandall@va.gov or 774-826-3161. E-Mail is preferred.

SOURCE SELECTION SENSITIVE WHEN COMPLETED*****NOT TO BE RELEASED OUTSIDE GOVERNMENT CHANNELS*****

PAST PERFORMANCE QUESTIONNAIRE – EXHIBIT A

PLEASE COMPLETE THE FOLLOWING IDENTIFYING INFORMATION AND PAST PERFORMANCE ASSESSMENT:

II. CONTRACTOR IDENTIFICATION:

Contractor:

Contract Number or Description:

Term of Contract/Period of Performance:

Estimated contract value

Describe product/service acquired:

Estimated volume/scope of Patients served _______________________________

III. RESPONDENT INFORMATION:

Name:

Organization:

Phone Number:

Relation to Program:

(i.e., Contracting Officer, Program Manager, Contract Specialist/Administrator, Contracting Officer's Technical Representative, etc.)

Time On Contract:

ASSESSMENT ELEMENTS: Narrative statements are vital. Please provide a narrative for each area. Attach additional pages if there is insufficient space in the comment space.

QUESTIONS

1. Were services rendered via a contract or were services provided on a call in basis?

2. Please describe the company adherence to contractual arrangements as it pertains to:

a. Timeliness of Service/Turnaround time for delivery (in days) following vendor receipt of order

b. Quality – Type / Incidence of errors

c. Volume - Was the vendor able to manage the volume within the established timeframes for delivery in the contract?

d. Type/Number of Billing Errors? Were invoices provided on paper or was an electronic process available/used?

e. Respect for HIPAA/Privacy/Information Security – for Patients / VA Sensitive Information.

f. Efficiency and professionalism of administrative and clinical staff? Does the company have periods of time of significant vacancies of office administrative and clinical staff?

g. Price

h. Development, access, use of company electronic patient records

3. Were there many instances of non performance (no shows) due to labor/staff delays or other reasons - and if so, did the company offer any alternatives?

4. Are there any areas in which you felt the company can improve its service?

5. Would you award another contract or purchase order to this company?

YES NO

6. Using the chart below, please provide an overall assessment of the contractor as to satisfactory performance.