PAST PERFORMANCE QUESTIONNAIRE PERFORMANCE SURVEY.pdf

36C25622Q0129- Veterans Health Care System of the Ozarks Mobile Lithotripsy Laser Services

SOURCE SELECTION INFORMATION

SEE FAR 2.101 and 3.104

FOR OFFICIAL USE ONLY

D.5 PAST PERFORMANCE SURVEY

This form is used to evaluate the past performance and experience of a prospective medical service provider company.

Completed form must be e-mailed prior proposal closing date to phyllis.shealey@va.gov.

SECTION I - Details of Company Being Evaluated

1. Company Name:

2. Service Provided:

3. Number and type of Personnel:

SECTION II - Details of Evaluator

1. Evaluator’s Company:

2. Evaluator’s Name:

3. Evaluators Title:

4. Evaluator’s Phone #:

5. Evaluator’s Email:

6. Start Date of Contract:

mailto:phyllis.shealey@va.gov

SECTION III - Customer Satisfaction/Quality of Service Questions

Rate the company’s product and service performance using the scale indicated for each question:

1. How would you rate satisfaction with the overall performance of this Company?

3= Excellent 2= Very Good 1= Acceptable 0= Unacceptable

3 2 1 0

2. How would you rate the extent that the Company responded to and attempted to correct any concerns, issues, or problems that appeared during performance of your contract?

3= Excellent 2= Very Good 1= Acceptable 0= Unacceptable

3 2 1 0

3. How would you rate the professionalism of the Company?

3= Excellent 2= Very Good 1= Acceptable 0= Unacceptable 3 2 1 0

4. What percentage of time did the Company provide on time services in accordance with contract requirements?

3= 90% of the time 2= 85-89% of the time

1= 80-84% of the time 0= <80% of the time

3 2 1 0

5. If given an opportunity, how likely is it you would conduct business with this Company again?

3= Very Likely 2= Likely 0= Not Likely

3 2 0

Please provide an explanation of all unacceptable ratings and make additional comments as applicable on all ratings in Section III.

SECTION IV – Service Performance Questions

Rate the company’s product and service performance using the scale indicated for each question

E xc el le nt

V er y G oo d

A cc ep ta bl e

U na cc ep ta bl e

N ot

A pp lic ab le

1. How would you rate satisfaction with the overall performance of the services provided? 4 3 2 1 0

2. Overall User Satisfaction with service: 4 3 2 1 0

3. Overall User Satisfaction with continuity of service: 4 3 2 1 0

4. Was the Monthly/Daily Effectiveness Level Consistently Met?

YES NO

Not Applicable

5. Was this contract for low & high-watt Holmium laser services? YES NO

Was this contract for C02 laser services? YES NO

Was this contract for Lithotripsy (ESWL) services? YES NO

Did technicians demonstrate a high-level of competency? YES NO

Did technicians complete & provide Laser Use Records promptly? YES NO N/A

Did Contractor meet established performance standards? YES NO

Was equipment maintenance provided regularly/ as indicated? YES NO

Was the Contractor able to respond promptly to emergency cases? YES NO N/A

Please provide an explanation of all unacceptable ratings and make additional comments as applicable on all ratings in Section IV or give any other comments regarding your medical services.

SECTION IV - Closing Comments

Pertinent comments regarding past performance of this company:

D.5 PAST PERFORMANCE SURVEY