Past_Performance_Questionnaire.docx

PAST PERFORMANCE QUESTIONNAIRE

Firm or Agency Name: ________________________________________________

Point of Contact: _____________________________________________________

Phone Number: ______________________________________________________

Contract Number: ____________________________________________________

Contract Period: ______________________________________________________

Approx. Dollar Value of contract: ______________________________________

PERFORMANCE LEVELS

RATING DEFINITION

E Exceptional / High Confidence. Based on the offeror’s performance record, essentially no doubt exists that the offeror will successfully perform the required effort.

VG

Very Good / Significant Confidence. Based on the offeror’s performance record, little doubt exists that the offeror will successfully perform the required effort.

S Satisfactory / Confidence. Based on the offeror’s performance record, some doubt exists that the offeror will successfully perform the required effort.

M Marginal / Little Confidence. Based on the offeror’s performance record, substantial doubt exists that the offeror will successfully perform the required effort. Changes to the offeror’s existing processes may be necessary in order to achieve contract requirements.

U Unsatisfactory / No Confidence. Based on the offeror’s performance record, extreme doubt exists that the offeror will successfully perform the required effort.

N/UC

Neutral / Unknown Confidence. No performance record identifiable, not part of contract performance

1. Technical Capacity

0. Rate the contractor’s compliance/ adherence to Joint Commission (home care) standards (e.g. staff training/competency records current and complete, process improvement plan, customer service data, compliance with safety standards such as dirty equipment separate from clean equipment in vehicles, etc.).

RATING_________

Comments:_________________________________________________________________________________________________________________________________________

B. Were reports and or documents required by the contract provided or available for on-site review? (e.g. infection control report, background checks on drivers, competencies or training for new employees, completed transports, etc.)

RATING_________

Comments:_________________________________________________________________________________________________________________________________________

C. Does the contractor adhere to prescribed equipment/services (e.g. doesn’t provide erroneous or extra services which are not authorized, equipment utilized is clean and meets specifications in SOW).

RATING_________

Comments:_________________________________________________________________________________________________________________________________________

E. Contractors capacity to meet the requirements of the contract. Contractor’s ability to identify and correct potential weakness in managerial capacity (e.g. resources, planning/scheduling, emergency plan, etc.)

RATING_________

Comments:_________________________________________________________________________________________________________________________________________

1. Performance-administrative functions

A. Does the contractor submit timely invoices, which accurately reflect correct services?

RATING_________

Comments:___________________________________________________________________________________________________________________________________________

1. Rate the working relationship between the contractor, local VA facility/health care system, and your designated Contracting Officer Representative staff. Would you have any reservations about soliciting this contractor in the future?

RATING_________

Comments:___________________________________________________________________________________________________________________________________________

C. Rate the responsiveness of the contractor to meeting required schedules, customer inquiries and or issues, and problem resolution.

RATING_________

Comments:___________________________________________________________________________________________________________________________________________

1. Rate the contractor personnel on professionalism, courtesy, and overall performance.

RATING_________

Comments:___________________________________________________________________________________________________________________________________________

You may provide additional comments regarding contract compliance, financial stability and efficiency, customer satisfaction, problems encountered and corrective actions taken.

Reviewer’s Name:___________________________________________________________________

Reviewer’s Signature:_________________________________________________________________