Past Performance Questionnaire.docx

Record Management Services

Past Performance Questionnaire

PAST PERFORMANCE QUESTIONNAIRE

RECORD STORAGE AND MANAGEMENT SERVICES

I. INTRODUCTION:

This questionnaire is designed to collect past performance information on offerors competing for award of a contract for Record Storage and Management Services for the Veterans Affairs Palo Alto Health Care System. Please complete the enclosed questionnaire and return it directly via email to Cindy.smith@va.gov. If you need more space than provided, please attach additional pages or use the last page of this form. Please include only relevant information. Further, Offeror must include a copy of each requested Past Performance Information page with proposal submission.

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: ________________________________________________

Contract Number: __________________ Total value of 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. Engineer, Technician, etc.)

Organization: _________________________________________________________________________

Phone Number: _______________________________________________________________________

IV. EXPLANATION OF CODES:

In Section V below of this questionnaire, we ask nine (9) questions regarding your contractor’s performance. If the rating is Marginal or Unacceptable, provide additional information in the appropriate block or in the remarks section of this form. 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. Does your contractor provide a NARA Certified Facility to store records?

Yes |_| No |_|

2. Does your contractor provide a NARA Certified Project Manager (PM)?

Yes |_| No |_|

Elaborate on PM Duties______________________________________________________________

3. Does your contractor provide scanning/indexing services?

Yes |_| No |_|

If yes, what was the total volume of records scanned on a yearly basis? ______________________

a. Within what time frame does the contractor provide you with viewable scanned images?

<24 hours |_| 24 hours |_| <48 hours |_| >48 hours |_|

b. How would you rate the quality of images scanned?

Poor |_| Fair |_| Good |_| Excellent|_|

Elaborate on Quality of Scanned Images: ______________________________________________________________

4. Does your contract require your contractor to pick up and deliver records from your site to contractor site and vice versa?

Yes |_| No |_|

a. If yes, Does the contractor provide transportation and personnel to complete the task?

Yes |_| No |_|

b. If yes, What was the TAT for pick up of records?

<24 hours |_| 24 hours |_| <48 hours |_| >48 hours |_|

Comments: ______________________________________________________________

c. If yes, what was the TAT delivery of Records?

<24 hours |_| 24 hours |_| <48 hours |_| >48 hours |_|

Comments: ______________________________________________________________

5. Does your contract require the contractor to have personnel on site to process record management request/ incoming records?

Yes |_| No |_|

Describe Process relating to Question #6: ______________________________________________________________

6. Does your contractor provide Release of Information Services?

Yes |_| No |_|

a. If yes, are contractor personnel provided on-site or off-site? ______________________________ Elaborate if necessary: ____________________________________________________________________

b. If no, could the contractor provide Release of Information Services if your contract required the services?

Yes |_| No |_|

Elaborate if necessary: ________________________________________________________________

7. Does your contractor store Radiology Film?

Yes |_| No |_|

8. Does your contractor store Pathology Tissue and Cytology Slides?

Yes |_| No |_|

9. Overall how would you rate the contractor’s performance?

ACCEPTABLE |_| UNACCEPTABLE |_|

Given the choice, would you award to this contractor again? Yes |_| No |_|

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

End of Questionnaire Source Selection Information – See FAR 3.104

VA261-17-Q-0263