PAST PERFORMANCE QUESTIONNAIRE.docx

PAST PERFORMANCE QUESTIONNAIRE

RFQ NUMBER: 36C24221Q0927

TITLE: VA Hudson Valley Healthcare System Ambulance Services OFFER / QUESTIONNAIRE DUE DATE: July 9, 2021, no later than 12:00 PM EST.

SECTION I: OFFERORS: COMPLETE requested information (Section I) and PROVIDE the questionnaire to the appropriate Respondent for each source of Past Performance Information mentioned in your Offer. The Respondent must have significant familiarity with the selected contract or subcontract in order to provide informed answers and comments about various aspects of the past performance.

NAME OF OFFEROR _____________________________________________________

NAME OF PAST PERFORMANCE SOURCE _________________________________

CONTRACT NUMBER and DATES OF SERVICE _____________________________

DESCRIPTION OF SERVICE ______________________________________________

TOTAL AWARDED PRICE ________________________________________________

SECTION II: RESPONDENT(S): COMPLETE the requested information (Section II) concerning the past performance of the above named Offeror relative to the referenced contract effort.

NAME OF RESPONDENT _________________________________________________

TITLE/POSITION ________________________________________________________

SIGNATURE ____________________________________________________________

(A) QUALITY OF SERVICE

1. Did the contractor comply with all contract requirements? ____Yes ___No Comments: ______________________________________________________________

2. With regard to timeliness of performance, were turnaround times of the contract met (i.e. completion of administrative requirements, task orders, milestones, production and delivery requirements?) ____Yes ____No Comments: ______________________________________________________________

3. Was the contractor's work found to be accurate and technically/clinically sound?

____Yes____ No Comments: ______________________________________________________________

4. How would you rate the quality of the contractor's end products / services furnished under this contract?

_____Outstanding _____Good_____ Acceptable ____ Unacceptable Comments: ______________________________________________________________

5. How would you rate the quality of the contractor's customer service furnished under this contract?

____Outstanding _____Good_____ Acceptable ____ Unacceptable Comments: ______________________________________________________________

(B) BUSINESS RELATIONS

6. Was contract Management efficient and responsive?

___Always ___Most of the time ___Sometimes ___Never

7. Did the contractor exhibit effective communication(s)?

___Always ___Most of the time ___Sometimes ___Never

8. Did the contractor exhibit reasonable and cooperative behavior?

___Always ___Most of the time ___Sometimes ___Never

9. Was the contractor flexible?

___Always ___Most of the time ___Sometimes ___Never

10. Did the contractor recommend effective solutions to problems?

___Always ___Most of the time ___Sometimes ___Never

11. Did the contractor exhibit a business-like concern for the interests of your Agency or Business:

___Always ___Most of the time ___Sometimes ___Never

12. How would you rate the contractor in the area of business relations generally?

____Outstanding _____Good_____ Acceptable ____ Unacceptable Comments on questions 6 through 11 above: ___________________________________

(C) CUSTOMER SATISFACTION

13. How would you rate the contractor on the basis of customer (end-user) satisfaction?

____Outstanding _____Good_____ Acceptable ____ Unacceptable

14. Would you select this firm again?

____Yes ____No Comments: ______________________________________________________________ End of Section II SECTION III: COMPLETED FORM MUST BE RETURNED TO THE VA CONTRACTING OFFICE PRIOR TO THE DUE DATE FOR RECEIPT OF QUOTES. THE OFFEROR MAY SUBMIT THE COMPLETED QUESTIONNAIRE ALONG WITH HIS/HER QUOTE; OR, THE RESPONDENT PROVIDING THE PERFORMANCE INFORMATION HEREIN MAY FORWARD THE COMPLETED FORM DIRECTLY TO THE CONTRACTING OFFICE, IF PREFERRED.

IN ALL CASES, THE COMPLETED PAST PERFORMANCE REFERENCES MUST REACH THE CONTRACTING OFFICE BY THE DATE AND TIME OFFERS ARE DUE. THE GOVERNMENT BEARS NO RESPONSIBILITY TO ASSURE QUESTIONNAIRES ARE PROPERLY RECEIVED.

POC: Natalie Acevedo, Contracting Officer NCO 2 Phone: 718-584-9000 x 2105 Email (preferred): Natalie.Acevedo@va.gov