Past Performance Questionnaire.docx

PAST/PRESENT PERFORMANCE QUESTIONNAIRE

SOLICITATION NUMBER – 36C24423R0047

ERIE AMBULANCE SERVICES

ERIE VAMC, PA

PLEASE COMPLETE THE FOLLOWING IDENTIFYING INFORMATION AND PAST PERFORMANCE ASSESSMENT. ONCE EVALUATION IS COMPLETED, SUBMIT FORM TO STEFANIE.CARTER3@VA.GOV AND REFERENCE ABOVE SOLICITATION NUMBER AND CONTRACTOR NAME IN SUBJECT LINE:

I. CONTRACTOR IDENTIFICATION:

Contractor:

Contract Number:

Period of Performance:

Negotiated price or cost at award:

Current estimated contract dollar amount:

Describe service acquired:

II. EVALUATOR INFORMATION:

Name:

Organization:

Phone Number:

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

Time on Contract:

III. ASSESSMENT ELEMENTS: Narrative statements are vital. Please provide a narrative for each element below and then an adjectival rating under Paragraphs III.A2, III.B.2, III.C.2, and an overall Past / Present Performance adjectival rating under par. III.F based on the Adjectival Rating Descriptions below. Attach additional pages if there is insufficient space in the comment space.

PERFORMANCE ADJECTIVAL RATINGS: Choose the appropriate adjective that most accurately describes the contractor’s performance based on the descriptions below.

Performance meets contractual requirements with most exceeded to the Government’s benefit. The contractual performance of the element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were highly effective.

Performance meets contractual requirements with some exceeded to the Government’s benefit. The contractual performance of the element being assessed was accomplished with no more than some minor problems for which corrective actions taken by the contractor was effective.

Performance meets contractual requirements. The contractual performance of the element contains some minor problems for which corrective actions taken by the contractor were satisfactory.

Performance does not meet some contractual requirements. The contractual performance of the element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented.

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

A. Quality of Services / Care

1. Narrative: Address the Contractor’s ability to provide therapeutic and rehabilitative services in a safe environment to homeless eligible Veterans. Provides quality of services including meals, transportation, laundry facilities, gender specific accommodations in the performance of the contract, and ADA accommodations.

2. Rating for Quality of Services / Care: (Please check one and provide a narrative explanation of a Marginal or Unsatisfactory rating):

|_| Excellent |_|Good |_|Satisfactory |_|Marginal |_|Unsatisfactory

B. QUALIFIED PERSONNEL:

1. Narrative: Describe the Contractor’s ability to provide qualified personnel (including experienced managers and/or supervisors).

2. Qualified Personnel: (Please check one and provide a narrative explanation of a Marginal or Unsatisfactory rating):

C. BUSINESS RELATIONS

1. Narrative: Address Contractor’s willingness to improve and correct noncompliance issues and concerns. Describe Contractor’s ability to correct problems and prevent or mitigate potential problems in a timely manner. Does Contractor display initiative and flexibility? Do Contractor personnel promote a strong working relationship with your agency/organization? Are Contractor personnel courteous and responsive? Do Contractor personnel interface effectively with your staff?

2. Rating for Business Relations: (Please check one and provide a narrative explanation of a Marginal or Unsatisfactory rating):

D. IDENTIFY THE CONTRACTOR’S OVERALL STRENGTHS AND WEAKNESSES:

E. GIVEN THE CHOICE, WOULD YOU AWARD TO THIS CONTRACTOR AGAIN?

YES |_| NO |_|

If no, please explain:

F. CONTRACTOR’S OVERALL PAST/PRESENT PERFORMANCE RATING:

(Please check one and provide a narrative explanation of a Marginal or Unsatisfactory rating):

Additional Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name/Signature Date

Title