S02 - Attachment 37 - Past Performance.docx

PAST PERFORMANCE SURVEY

SUBJECT: Past Performance Survey for Bonner County, Idaho Community Based Outpatient Clinic (CBOC

FOR PROVIDERS OF PAST PERFORMANCE INFORMATION

The VISN 20 Contracting Office has issued a solicitation to provide CBOC services in the Bonner County area of Idaho.

Past performance information will be used to evaluate proposals received. Section A of the enclosed survey lists the contractor who has identified your office as a source to evaluate their past performance. Section A also authorizes release of this information to the VISN 20 Contracting Office.

An individual knowledgeable of the contractor’s quality of services rendered will complete the survey, providing comments wherever applicable. However, supplemental information from others in your organization is encouraged. If evaluating more than one contract for the same contractor, use a separate survey for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing it is greatly appreciated. Complete the survey and send electronically to scott.reed2@va.gov no later than 10 December 2017.

Attachment 37

PAST PERFORMANCE SURVEY

SECTION A: Contractor Information (to be completed by the contractor for whom past performance information is being collected, prior to forwarding to respondent.)

1. Prospective Government Contractor’s ______________________________________

2. Contractor Point of Contact: ___________________________________________

3. Phone number (with area code):___________________________________________

4. Contract number: ___________________________________________

5. Description of Services provided under contract referenced in item 4: _____________________________________________________________________________

6. Contract award date: ___________ Contract award amount: _________________

7. Period of Performance: ________________________________________

8. Authorization is hereby granted to provide the information requested in this survey to VISN 20 Contracting.

(Signature)

SECTION B: Respondent Information (to be completed by respondent)

(Title)

Respondent will complete survey and submit immediately to scott.reed2@va.gov .

The following Rating Scale provides the definitions for the Past Performance ratings to be assessed:

E EXCEPTIONAL

Past performance has met contractual requirements and has exceeded some to the respondent's benefit. Contractual performance was accomplished with few minor problems for which corrective action(s) taken by the contractor were highly effective.

V VERY GOOD

Past performance has met contractual requirements and has exceeded some to the respondent's benefit. Contractual performance was accomplished with some minor problem(s) for which corrective action(s) taken by the contractor were effective.

S SATISFACTORY

Past performance has met contractual requirements. Contractual performance contains some minor problem(s) for which corrective action(s) taken by the contractor appear or where satisfactory.

M MARGINAL

Past performance has not met some contractual requirements. Contractual performance reflects a serious problem for which either the contractor has not yet identified correction action(s), or the proposed corrective action(s) appear only marginally effective or were not fully implemented.

U UNSATISFACTORY

Past performance has not met most contractual requirements, and recovery did not occur or was not in a timely manner. Contractual performance contains serious problem(s) for which the contractor's corrective action(s) appear or were ineffective.

The questions on the survey will be rated in accordance with the definitions provided in the Rating Scale. Please provide an explanation in the space provided for any unsatisfactory or marginal rating.

QUALITY OF SERVICE

1. Rate the contractor’s compliance with contractual requirements.

E V S M U

2. Rate the contractor’s workforce quality.

E V S M U

3. Rate the contractor’s workforce stability.

E V S M U

4. Overall rating of contractor quality of service.

E V S M U

QUALITY OF SERVICE COMMENTS:

SCHEDULE

1. Transition to the contractor at the beginning of the period of performance was within required time period specified by contract requirements.

E V S M U

2. Contractor provides services within the required time period specified by contract requirements (e.g., providing patient appointments within 7 days, if 7 days is required by the contract.)

E V S M U

3. Overall rating of contractor conformance to schedule.

SCHEDULE COMMENTS:

BUSINESS RELATIONS

1. Rate the working relationship between contractor’s management, your company and your designated representatives (to include inspection personnel).

E V S M U

2. Rate the contractor’s ability to submit reports and/or invoices in a timely manner. Are they complete and accurate?

E V S M U

3. Rate the contractor’s responsiveness to customer complaint resolution.

E V S M U

4. Overall rating of contractor’s business relations.

BUSINESS RELATIONS COMMENTS:

How would you feel about awarding another contract to this contractor?

______ Would not hesitate to award another contract to this contractor.

______ Would most likely award another contract to this contractor.

______ Would think twice about awarding another contract to this contractor, but would do so if no better alternative existed.

______ Would not award another contract to this contractor.

ADDITIONAL COMMENTS: