S02. Attachment D.3 _ Past Performance Questionnaire.pdf

ATTACHMENT D.3 – Dialysis

PAST PERFORMANCE QUESTIONNAIRE

1. The Contractor identified below has requested that you complete a past performance questionnaire on their behalf. This questionnaire will be used by the Contracting Officer, Billy Morris, to assess the likelihood that the Contractor will perform successfully on an impending requirement for inpatient dialysis services at the Veterans Health Care System of the Ozarks Hospital, 1100 North College Avenue, Fayetteville, Arkansas. Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME _________________________________________

REFERENCED CONTRACT # _________________________________________

2. Background. Contractor to provide all necessary equipment, personnel, dialysis-specific supplies, and supervision to perform inpatient hemodialysis treatments at the Veterans Health Care System of the Ozarks (VHSO), 1100 North College Avenue, Fayetteville, Arkansas. This will include all inpatient hemodialysis needs, both acute and/or chronic.

3. GENERAL INFORMATION: (Completed by Reference of Contractor being evaluated)

Name of Government or Commercial Organization:______________________________

Address:_________________________________

Contract Number:______________________________ Brief Description of services (used for determination of relevancy):

Contractor Performed as: Prime Contractor Sub-Contractor Dates of Performance (if current include expiration):____________________________ (used for determination of recency) Total Cost of Contract:__________________Award/Incentive/Deduction_____________ Any terminations for cause or default? Circle YES or NO If yes, brief explanation:___________________________ Point Of Contact/COR:____________________________ Title:___________________________________ Telephone Number:____________________________ Point of Contact’s email address:______________________

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

Q1. Did the contractor provide Dialysis services (Y/N)? ___________

Q2. If Contractor did not provide the services above; please provide a short description of the type of services provided.

Q3. Did the contractor provide any additional services (Y/N)?________________ If so, what types?

5. Please use the below matrix to answer questions relating to performance using the following template.

Please evaluate the past performance using only the following ratings without variation. If the rating is Excellent, Good, Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form.

“E” = Excellent = Very High Confidence and Performance greatly exceeded the contract requirements.

“G” = Good = High Confidence and Performance exceeded the contract requirements.

“S” = Satisfactory = Confidence and Performance met the contract requirements.

“M” = Marginal = Low Confidence and Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory.

“U” = Unsatisfactory = NO Confidence and Performance was poor and/or did not satisfy contract requirements.

Please write in “not applicable” or “neutral” if unable to rate a certain question. For any E, G, M, or U rating please provide a short summary explanation of rating.

Please rate and provide information/comments for the following: Circle one Q1. To what extent did the contractor comply with overall contract requirements? E G S M U

Q2. How successful was the Contractor in filling all requirements? E G S M U

Q3. How would you rate the quality of the Physicians and other staff provided by this Contractor in terms of technical competence, reliability, and demeanor with patients and staff?

E G S M U

ATTACHMENT D.10 – Franklin CBOC

Q4. To what extent was the Contractor able to meet unexpected and short notice changes and/or requirements (e.g. unexpected shift vacancies, training requirements).

E G S M U

Q5. How would you rate the Contractor’s administrative staff as pertains to communication with your organization’s key personnel, their ability to complete credentialing and privileging, billing and invoicing processes, and overall contract management and professionalism?

E G S M U

Q6. Did you issue any cure notices, show cause letters, or suspension of payment? If yes, please explain.

Yes No

Q7. Would you award another contract to the Contractor being evaluated? If no, please explain:

Yes No

ATTACHMENT D.10 – Franklin CBOC

Additional Comments pertaining to contractor performance in particular to Quality of Service, Timeliness of Performance, and Business Relations:

Printed Name & Signature of Evaluator Date

6. Thank you for your time! Please return completed questionnaire to Billy Morris, Contracting Officer, for this acquisition, at billy.morris@va.gov not later than the due date from block 8 SF1449.

mailto:billy.morris@va.gov

PAST PERFORMANCE QUESTIONNAIRE