S02 EXHIBIT O - PAST PERFORMANCE QUESTIONNAIRE.pdf

PAST PERFORMANCE QUESTIONNAIRE

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

Solicitation Number 36C24WR0018 Project/Requirement Mt Vernon CBOC Customer/Agency Puget Sound Healthcare System

1. Prospective Government Contractor’s______________________________________ Name and Address: ______________________________________

2. Contractor Point of Contact: ___________________________________________

3. Phone number (with area code): ___________________________________________

4. Assessor Contract Award number: _________________________________________

5. Description of Services provided under contract:

6. Contract award date: ___________ Contract Amount: Initial ___________Final ____

7. Period of Performance or Delivery Date: _________________________

ASSESSOR INFORMATION:

Assessor Name Title Phone Number/Email Address

8. Authorization is hereby granted to provide the information requested in this questionnaire to RPO West Contracting Activity via email to Kenneth.chapman3@VA.GOV

(Signature)

(Name and Title of Authorizing Official) (Date)

SECTION B: Assessors Information (to be completed by assessors).

RATING SCALE Definitions Past Performance Ratings and Definitions

E Exceptional

Offer’s past performance record provides essentially no doubt that the offeror will successfully perform the required effort.

The proposal demonstrates very low risk.

S Satisfactory

Offer’s past performance record provides little doubt that the offeror will successfully perform the required effort. The proposal demonstrates low risk.

M Marginal

Offer’s past performance record, although satisfactory, provides some doubt that the offeror will successfully perform the required effort. The proposal demonstrates moderate risk.

U Unsatisfactory

Offer’s past performance record provides substantial doubt that the offeror will successfully perform the required effort.

The proposal demonstrates high risk.

N Neutral

The offeror has no relevant past performance record. A thorough search was unable to identify any past performance. Will not rate favorably or unfavorably. The proposal demonstrates unknown risk.

The questions on the survey (see below) shall be rated in accordance with the definitions provided in the Rating Scale. Any unsatisfactory or marginal rating shall be supplemented with an explanation in the space provided.

QUALITY OF SERVICE

1. Rate the contractor’s compliance with contractual requirements. E S M U N

2. Overall rating of contractor quality of service. E S M U N

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

SCHEDULE

1. Delivery of service was within required time period specified by contract requirements. E S M U N

2. Rate the contractor’s ability to control cost and submit invoices.

Are invoices complete, accurate, and timely? E S M U N

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

BUSINESS RELATIONS

1. Overall rating of contractor’s business practices (e.g., maintaining A positive working relationship, business ethics, timely and effectively

Resolution of any problems, etc.) E S M U N

2. Rate the working relationship between contractor’s management, and your company (i.e., contractor’s history of reasonable and cooperative behavior, commitment of customer satisfaction; concern for the interest of the customer). E S M U N

3. Rate the contractor's ability to submit required reports and/or invoices in a timely manner. E S M U N

4. Rate the contractor’s responsiveness to customer complaint resolution. E S M U N

5. Overall rating of contractor’s business relations. E S M U N

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

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.

______ Do not wish to award another contract to this contractor.

______ Would not award another contract to this contractor.

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

Overall Rating of Contractor’s performance (quality, schedule, business relations,) on contract being assessed.

Exceptional Satisfactory Marginal Unsatisfactory Neutral

VII. General Comments:

ASSESSOR:

Identify your role in the contract award or administration and the period of your involvement.

Role Period of Involvement

Contract Specialist/LEASE

CONTRACTING OFFICER

Technical Project Lead/Project Officer

OTHERS

(Signature) (Date) (Typed or Printed Name) (Organization Name)

(Phone Number)

Assessor Name