VA244-17-R-1154-008.docx

ATTACHMENT 7

PAST PERFORMANCE QUESTIONNAIRE

SOLICITATION NUMBER – VA244-17-R-1154

NEUROPHYSIOLOGY SERVICES

I. Please complete this questionnaire. For assistance with this form, please notify the contract specialist listed at the address below. If you need more space than provided, please attach additional pages. Please include only relevant information. Responses will be treated as source selection sensitive information. Please submit this information on or before the proposal due date. Return the completed questionnaire either by email, mail, to the following address:

II. EXPLANATION OF CODES:

CODE PERFORMANCE LEVEL

PLEASE COMPLETE THE FOLLOWING IDENTIFYING INFORMATION AND PAST PERFORMANCE ASSESSMENT:

III. CONTRACTOR IDENTIFICATION:

Contractor:

Contract Number:

Period of Performance:

Negotiated price or cost at award:

Current estimated contract dollar amount:

Describe product/service acquired:

IV. EVALUATOR INFORMATION:

Name:

Organization:

Phone Number:

Relation to Program:

(i.e., Contracting Officer, Program Manager, Contract Specialist/Administrator, Contracting Officer's Technical Representative, etc.)

Time On Contract:

ASSESSMENT ELEMENTS: Place an “X” in the appropriate box next to the letter for each item on the questionnaire. Narrative statements are vital. Please provide a supporting narrative for each area. Attach additional pages if there is insufficient space in the comment space.

A. QUALITY OF PRODUCT/SERVICE (e.g., Does the contractor provide qualified personnel, necessary equipment, and quality control for performance of your contract?)

E |_| A |_| U |_| N |_|

1. Did the personnel provided meet or exceed your requirement? Yes |_| No |_|

2. Were any of the contract personnel released and/or replaced due to qualifications, performance, or behavior? Yes |_| No |_|

3. Were all positions required by the contract filled by the date required? Yes |_| No |_|

B. SCHEDULE (i.e., Is the work performed in a timely manner and in accordance with the requirement?)

E |_| A |_| U |_| N |_|

1. Did personnel arrive for duty on time, remain on duty as required, and report off appropriately before leaving duty? Yes |_| No |_|

2. Did personnel submit accurate and timely records of their time worked? Yes |_|No |_|

3. Were leave issues, and vacation handled appropriately and did contractor provide for absences as required? Yes |_| No |_|

C. BUSINESS RELATIONS (e.g., Are contractor personnel promoting a strong working relationship with the Government? Does the contractor adequately address and make efforts to resolve issues/problems concerning site employees? Does the contractor show initiative? Were contractor personnel courteous and responsive? Does the contractor interface effectively with your staff, etc.?)

E |_| A |_| U |_| N |_|

1. Were accurate and clear invoices submitted in a timely fashion? Yes |_| No |_|

2. Did personnel resolve work-related problems in a satisfactory manner? Yes |_| No |_|

3. Were contract personnel proactive in their approach to problem identification and prevention?

Yes |_| No |_|

D. Did the contractor adhere to their technical and management approach? Yes |_|No |_|

If no, explain what was different.

E. Please comment on any other contractor information you consider relevant to this evaluation.

F. Identify the contractor’s overall strengths and weaknesses. __________________________________________________________________________________________________________________________________________________________________________________________________________________

G. Given the choice, would you award to this contractor again? Yes |_| No |_|