TeleRadiology_Attachment_7_Past_Performance_Questionnaire_8-20-2014.doc

ATTACHMENT 7

PAST PERFORMANCE QUESTIONNAIRE

TELERADIOLOGY SERVICES

I. INTRODUCTION:

This questionnaire is designed to collect past performance information on Offerors competing for award of a contract for TeleRadiology services for the U.S. Immigration Customs & Enforcement (ICE) Health Service Corps (IHSC). Please complete the enclosed questionnaire and email it directly to Tonya.modlin@ice.dhs.gov or fax it to the attention of Tonya Modlin at 202-732-7449. This questionnaire can be duplicated as necessary. For assistance with this form or to request an electronic copy please notify the Contracting Officer listed above. Handwritten responses will be accepted. If you need more space than provided, please attach additional pages or write on the last page. Please include only relevant information. Responses will be treated as source selection sensitive. Past Performance must be submitted not later than July 30, 2014 by 12:00pm.

II. CUSTOMER/CLIENT IDENTIFICATION:

The following information pertains to the organization and contract information of the customer completing the questionnaire:

Your company or agency name: __________________________________________________

Name of contractor being evaluated: ______________________________________________

Your contract number: __________________ Total value of your contract: $_______________

Performance Period: Basic Period: ____________________ Option Periods:_______________

Brief description of services provided: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

III. EVALUATOR INFORMATION:

The following information pertains to the person completing this questionnaire.

Name/Title:____________________________________________________________________(e.g. Radiologist, Technician, Contracting Officer, etc.)

Organization:___________________________________________________________________

Phone Number:_________________________________________________________________

IV.

Explanation of codes:

In Section V below of this questionnaire we ask 22 questions regarding your contractor’s performance. Please use the following ratings when rating the contractor’s performance:

CODE

PERFORMANCE RATINGS

V. QUESTIONS CONCERNING PAST PEFORMANCE:

Place an “X” in the appropriate box next to the letter for each item on the questionnaire. Narrative statements are vital. Please provide a supporting narrative for each area. Attach additional pages if there is insufficient space in the comment space.

1. On average, how many examinations are read each month?

FORMCHECKBOX

Less than 250 FORMCHECKBOX

250 - 349 FORMCHECKBOX

350 - 399 FORMCHECKBOX

400 - 999 FORMCHECKBOX

1000 and above

2. What type of examinations do you refer to the contractor for review?

MRI __ CT __ US __ Chest X-Ray __ Other __

If another type of examination is used, what type?_____________________________________

3. Have you experienced any problems with backlog of studies?

YES

FORMCHECKBOX

NO

FORMCHECKBOX

Comments for Question 3:

4. Does your contract require 24 hours per day on-demand service?

YES

FORMCHECKBOX

NO

FORMCHECKBOX

If so, what type of on-demand service was provided?

5. Does the contractor’s level of performance vary between weekdays and weekends/holidays or between daytime and nighttime?

YES

FORMCHECKBOX

NO

FORMCHECKBOX

6. Has the contractor ever had a problem with meeting the timeliness standards of the contract?

YES

FORMCHECKBOX

NO

FORMCHECKBOX

If timeliness is a problem, what was/were the cause(s) of delay? Has the contractor corrected the problem?

Comments for Question 6:

7. Rate the contractor’s availability for telephone consults during the contract hours of operation?

E FORMCHECKBOX

V FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

U FORMCHECKBOX

N FORMCHECKBOX

Comments for Question 7:

8. Rate the contractor’s technical knowledge and reliability during telephone consults?

E FORMCHECKBOX

V FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

U FORMCHECKBOX

N FORMCHECKBOX

Comments for Question 8: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9. Rate the contractor’s reliability and judgment in contacting referring radiologist when urgent/unexpected findings are found?

E FORMCHECKBOX

V FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

U FORMCHECKBOX

N FORMCHECKBOX

10. Does your contract include response time(s) for various reports to be submitted?

YES

FORMCHECKBOX

NO

FORMCHECKBOX

Please specify your response time requirements: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please rate how well the contractor meets the contract response time standards.

E FORMCHECKBOX

V FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

U FORMCHECKBOX

N FORMCHECKBOX

11. When erroneous reports are discovered does the contractor promptly amend the report and immediately notify you of significant errors (i.e. those that could reasonably change the patient’s management)?

YES

FORMCHECKBOX

NO

FORMCHECKBOX

If not, explain how often this happens and how the contractor reconciles the report.

12. Rate the overall quality/accuracy of the reports submitted.

E FORMCHECKBOX

V FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

U FORMCHECKBOX

N FORMCHECKBOX

Comments for Question 12:

13. Rate your level of satisfaction with the procedure utilized for sending reports from the contractor to your institution

E FORMCHECKBOX

V FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

U FORMCHECKBOX

N FORMCHECKBOX

14. What report-sending procedure did you utilize?

FORMCHECKBOX

Contractor uploads reports electronically? FORMCHECKBOX Contractor provides hardcopy reports (paper)

Comments:

15. Rate the contractor’s willingness to expedite reports when immediate results are required.

E FORMCHECKBOX

V FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

U FORMCHECKBOX

N FORMCHECKBOX

Comments for Question 15: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

16. Have you experienced any problems with contractor employees being credentialed?

YES

FORMCHECKBOX

NO

FORMCHECKBOX

Comments for Question 16:

17. Rate the contractor’s interaction with your organization; e.g. courteous, professional, proper sense of urgency to your needs.

E FORMCHECKBOX

V FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

U FORMCHECKBOX

N FORMCHECKBOX

Comments for Question 17:

18. Has this contract been partially or completely terminated for default or convenience or are there any pending terminations?

YES

FORMCHECKBOX

NO

FORMCHECKBOX

DEFAULT FORMCHECKBOX

CONVENIENCE FORMCHECKBOX

If yes, explain (e.g., inability to meet cost, performance, or delivery schedules).

Comments for Question 18:

19. Did you make any significant changes in service or procedures during the life of the contract?

YES

FORMCHECKBOX

NO

FORMCHECKBOX

If so, what were the changes? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

20. What is your overall rating of the contractor?

E FORMCHECKBOX

V FORMCHECKBOX

S FORMCHECKBOX

M FORMCHECKBOX

U FORMCHECKBOX

21. Did the contract call for a transition plan, if so what was the duration of the transition?

YES FORMCHECKBOX

NO FORMCHECKBOX

Explain what was involved in the transition plan.

22. Given the choice, would you award to this contractor again?

YES FORMCHECKBOX

NO FORMCHECKBOX

Explain why you would not enter into another contract with this firm.