S02 - Attachment D.5 Past Performance Questionnaire.pdf

PAST PERFORMANCE QUESTIONNAIRE

Services

Department of Veterans Affairs (VA) Network Contracting Office - 8

Message to the assessor: Your assistance is requested by , the VA Contract Specialist to assist with establishing the performance history for the Company ( ) named below for which this Past Performance Questionnaire is being completed. In efforts to expedite receipt of the requested information, the Contracting Office respectfully requests that you do not mail hard copies. Instead, please e-mail the completed past performance questionnaire directly to @va.gov. If there is not enough space provided, please attach additional information/pages to this questionnaire. Please return the past performance questionnaire on or before 6/10 directly to va.gov.

1. Name of Contractor: Contract #

Title/Description of Services: _____________________________ Location of performance: _________

Based upon the definitions below, indicate your assessment of the contractor’s performance. Your assessment should consider the quoter’s performance in accordance with the contractual requirements. Please include the period of performance (POP) and contract value:

POP: ___________________________________ Total contract value ($): _________________________

2. Brief description of scope of work performed by Company (Quoter): ________________________________

3. Any terminations for cause or default? Circle YES or NO If yes, brief explanation: ________________________________________________________________

4. Any contract discrepancy reports filed? Circle YES or NO If yes, brief explanation: ________________________________________________________________

Point of Contact/Contracting Officer’s Representative:

Name: _______________________ Title: ________________________ Telephone Number: ____________ Email address: _____________

5. Please answer the following questions pertaining to the relevancy of the services provided to you as compared to the description in paragraph 2.

Question 1: Did the contractor provide On-site Physician Services that included

Yes or No

If yes, brief explanation: _______________________________________________________

Question 2: Did the contractor

? Yes or No If yes, what types of ? __________________________________________________

Question 3: Was the contractor able to meet the staffing needs of the contract without interruption of services due to the absence of any key personnel? Yes or No

If no, brief explanation: ________________________________________________________

EVALUATION: Please rate the quoter using the guide below. Explanatory narratives for as many responses as possible would be appreciated. These narratives need not be lengthy, just detailed. Attach additional pages if more space is needed. Rate by placing an (X) in the appropriate rating box.

Assessment Definition

Completed scheduled services in a timely manner per the Performance Work Statement (PWS).

O A S U

Compliance with contractual Terms and Conditions. O A S U Demonstrated ability to hire, maintain, and replace, if necessary, qualified k e y personnel during the contract period.

O A S U

Provided effective quality control and/or inspection procedures to meet contract requirements.

O A S U

Corrected deficiencies in timely manner and pursuant to the quoter’s quality control procedures.

O A S U

Exhibited knowledge of and compliance with Government (or other) regulations and industry standards.

O A S U

How effective was the quoter in responding to urgent requests in a timely manner per the Performance Work Statement (PWS)?

O A S U

To what extent was the quoter able to solve contract performance problems without extensive guidance from procurement or technical staff.

O A S U

Provides timely and accurate documents, records, and invoices as required by the contract.

O A S U

Would you award similar contracts to this quoter? Please provide explanation for your response in the additional comments section.

YES NO

Rate the Quoter’s OVERALL quality of performance under the contract performed.

O A S U

EXPLANATION OF OVERALL QUALITY OF PERFORMANCE RATING GIVEN:

ADDITIONAL COMMENTS (as required): ________________________________________________

Name of Assessor: __________________ Signature: __________________ Date: __________ Position Title: Phone:

Company/Agency: ______________________________ Email: _____________________

The Quoter’s performance met contractual requirements and exceeded many requirements to the Client’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions were taken by the quoter.

The Q the Cl for wh

Outstanding (O)

Above Average (A) The Quoter’s performance met contractual requirements and exceeded some requirements to the Client’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the quoter were effective.

Satisfactory (S) The Quoter’s performance met contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the quoter were satisfactory.

Unacceptable (U) Performance did not meet contractual requirements. The contractual performance reflected a serious problem for which the quoter has yet to identify corrective actions or the quoter’s proposed actions appear only marginally effective or were not fully implemented.