S02_Past Performance Questionnaire.docx

ATTACHEMENT 2 – PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for the James H. Quillen VA Medical Center, NCO 9

PAST PERFORMANCE INSTRUCTIONS

The NCO 9 Network Contracting Activity, Murfreesboro, Tennessee has issued a solicitation to provide Non-Emergent Ambulance Transportation Services for the James H. Quillen VA Medical Center.

Past performance information will be used to evaluate proposals received. Section A is to be completed by the Offeror. Section A of the enclosed questionnaire 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 NCO 9 Network Contracting Activity, Murfreesboro, Tennessee.

The Offeror must provide this entire document to each of its assessors. The Offeror shall only submit with its proposal (by the closing date if the Solicitation) copies of Section A of the questionnaire as provided to the assessors.

Section B in its entirety is to be completed by the assessor(s). An individual assessor knowledgeable of the contractor’s quality of supplies and services rendered is requested to verify, complete the questionnaire, and submit to the Contracting Office. If evaluating more than one contract for the same contractor, use a separate questionnaire for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing your assessment is greatly appreciated. The questionnaire should be completed as soon as possible but not later than October 12, 2022. Assessor is requested to send electronically to nina.jones2@va.gov.

Assessor: Please do not send this information to the Offeror being evaluated.

Thank you in advance for your cooperation and expeditious response to this request.

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)

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: _______________________

ASSESOR INFORMATION:

Assessor’s Name

Title

Phone Number/Email Address

8. Authorization is hereby granted to provide the information requested in this questionnaire to NCO 9 Network Contracting Activity, Murfreesboro, Tennessee.

(Signature)

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

RATING SCALE Definitions

Past Performance Evaluation Ratings

The questions on the survey 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

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:__________________________

SCHEDULE

1. Delivery of service was within required time period specified by contract requirements. A U

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

Are invoices complete, accurate, and timely? A U

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 effective resolution of any problems, etc.). A U

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). A U

3. Rate the contractor’s ability to submit required reports and/or invoices in a timely manner. A U

4. Rate the contractor’s responsiveness to customer complaint

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:__________________________

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

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:__________________________

Overall Rating of Contractor’s Performance (quality, schedule, business relations) on the contract being assessed:

GENERAL COMMENTS:________________________________________________________

ASSESSOR:

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

Contract Specialist/Contracting Officer

Technical Project Lead/Project Officer

Other: