Past Performance Survey.pdf
PDF 74 KB Posted
- Attached to
- Perfusionist Services for VAPAHCS Federal contract opportunity
- Solicitation number
- 36C26121Q0045
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C26121Q0045 0002.pdf | ||
| 36C26121Q0045 0001.pdf | ||
| PWS Perfusionist Services (Rev 08-18-2021).pdf | ||
| D.1 Quality Assurance Surveillance Plan.pdf | ||
| D.2 Contractor Rules of Behavior.pdf | ||
| D.4 Contractor Conflict of Interests Certification Statement.pdf | ||
| D.1 Quality Assurance Surveillance Plan.docx | DOCX document | |
| D.3 Contractor Certification of Compliance with the Immigration and Nationality Act of 1952.pdf | ||
| 36C26121Q0045.pdf |
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Text version
Past Performance Survey
Reference Instructions: The Department of Veterans Affairs is seeking vendors for award of a VA contract for Perfusion Services for five ordering periods. You have been identified as a reference and your comments would be appreciated. Your comments are considered Source Selection Sensitive;
therefore, you are advised that the release of the names of individuals providing reference information about vendor’s past performance is prohibited. Survey should be completed by evaluator and submitted no later than August 27, 2021 @ 4:30pm PST via email directly to Emily.Trinh@va.gov.
Note: Incomplete or unsigned surveys will not be considered.
Company being evaluated_____________________________________________________
Period of Performance: _______________________________________________________
What was the average monthly volume of services provided? (Number of cases per month?
Average number of hours per case? _______________________________________________
Name and title/position of evaluator: ____________________________________________
Contact telephone number: ____________________________________________________
Contact e-mail address: _______________________________________________________
Please evaluate the past performance using only the following ratings without variation. If the rating is other than Fully Acceptable, please provide additional information in the appropriate block or in the remarks section of this form.
S = Superior Performance
V = Very Good with very few issues
F = Fully Acceptable/Good
M = Marginally Acceptable
U = Unacceptable Performance
Please rate and provide information/comments for the following:
Circle/Indicate
Selection
Q1. Rate how well the contractor complies with requirements and/or expectations? S V F M U
Q2. Rate contractor’s knowledge and expertise in providing perfusion services. S V F M U
Q3. Rate contractor’s knowledge and expertise in providing Cardio-Pulmonary
Bypassservices.
S V F M U
Q4: Rate how well the contractor was able to provide on-call services. S V F M U
Q5: Rate this contractor’s perfusion staff. S V F M U
Q6: Rate the level of access to the contractor’s personnel. (i.e. Did they respond in a timely manner? Did they meet the requirements of being available and responding as according to the contract?)
S V F M U mailto:Emily.Trinh@va.gov
Q7: Rate overall ease of contractor’s scheduling process. S V F M U
Q8: Rate how well contractor protects the privacy of patients. S V F M U
Q9 . Would you award another contract to the firm being evaluated? If no, please explain:
Yes No
Additional Remarks: Please use this space to indicate anything else you would like to say about the contractor being referenced or to list anything you especially liked or disliked about this contractor
Signature of Evaluator
Date
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