EXHIBIT Z - Past Performance Questionnaire.docx

PAST PERFORMANCE QUESTIONNAIRE

Subject: Past Performance Questionnaire for Adams County, PA

PAST PERFORMANCE INSTRUCTIONS

The NCO4 Network Contracting Office, Pittsburgh, Pennsylvania has issued a solicitation to provide leased space for a Community Base Outpatient Clinic (CBOC) lease in Adams County, PA.

Past performance information will be used to evaluate proposals received. Section A is to be completed by the Offeror. Section A of the enclosed questionnaire lists the contractor who has identified your office as a source to evaluate their past performance. Section A also authorizes release of this information to NCO4 Network Contracting Office, Pittsburgh, Pennsylvania.

The Offeror must provide this entire document to each of its assessors. The Offeror shall only submit with this proposal (by the closing date of the Solicitation) copies of Section A of the questionnaire as provided to the assessors.

Section B in its entirely is to be completed by the assessor(s). An individual assessor knowledgeable of the contractor’s quality of supplies and services rendered is requested to verify, complete the questionnaire and submit to the Contracting Office. If evaluating more than one contract for the same contractor, use a separate questionnaire for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing your assessment is greatly appreciated. The questionnaire should be completed as soon as possible but not later than (DATE). Assessor is requested to send electronically to Doretha.Jordan@va.gov. Assessor: Please do not send this information to the Offeror being evaluated.

Thankyou in advance for your cooperation and expeditious response to this request.

PAST PERFORMANCE QUESTIONAIRE

SECTION A: Contractor Information (to be completed by the contractor for who past performance information is being collected, prior to forwarding to assessors)

Solicitation Number

Project/Requirement

Agency

1. Prospective Government Contractor’s __________________________________________________

5. Description of Services provided under contract:

6. Contract award date: ___________________ Contract Amount: Initial ________ Final ___________

7. Period of Performance: ______________________________________________________________

ASSESSOR INFORMATION:

Assessor Name

Title

Phone Number & Email Address

8. Authorization is hereby granted to provide the information request in this questionnaire to NCO4 Network Contracting Office, Pittsburgh, Pennsylvania.

(Signature)

SECTION B: Assessors Information (to be completed by assessors).

Past Performance Evaluation Ratings

The questions on the survey (see below) shall be rated in accordance with the definitions provided in the Rating Scale. Any unsatisfactory or marginal rating shall be supplemented with an explanation in the space provided.

QUALITY OF SERVICE

1. Rate the contractor’s compliance with contractual requirements. E S M U N

2. Overall rating of contractor quality of service. E S M U N

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

SCHEDULE

1. Delivery of service was within required time period specified by E S M U N contract requirements.

3. Rate the contractor’s ability to control cost and submit invoices. E S M U N Are invoices complete, accurate, and timely?

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

BUSUNESS RELATIONS

1. Overall rating of contractor’s business practices (e.g. maintaining A positive working relationship, business ethics, timely and effectively Resolution of any problems, etc.) E S M U N

2. Rate the working relationship between contractor’s management, and your company (i.e. contractor’s history of reasonable and cooperative behavior, commitment of customer satisfaction; concern for the interest of the customer). E S M U N

3. Rate the contractor’s ability to submit required reports and/ or invoices in a timely manner.

E S M U N

4. Rate the contractor’s responsiveness to customer complaint resolution. E S M U N

5. Overall rating of contractor’s business relations. E S M U N

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

How would you feel about another contract to this contractor?

___________Would not hesitate to award another contract to this contractor.

___________Would mostly likely award another contract to this contractor.

___________Would think twice about awarding another contract to this contractor, but would do so if there was no alternative existed.

___________Do not wish to award another contract to this contractor.

___________Would not award another contract to this contractor.

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

Overall Rating of Contractor’s performance (quality, schedule, business relations) on contract being assessed.

VII. General Comments:

ASSESSOR:

Identify your role in the contract award or administration and the period of your involvement.

Contract Specialist/Contracting Officer

Technical Project Lead/Project Officer

OTHERS

(Phone Number)