VA257-17-R-0506-010.docx

D.9 VA257-17-R-0506

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 to assess the likelihood that the Contractor will perform successfully on an impending requirement for the VA North Texas Health Care System (VANTHCS). Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME _________________________________________

REFERENCED CONTRACT # _________________________________________

2. Background. The VANTHCS requires Community Based Outpatient Clinic (CBOC) services providing Primary Care (PC), space and administrative support to veterans, primarily residing in Granbury, Texas.

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

Name of Government or Commercial Organization:

Name of Person Completing Response: __________________________________________

Title: Phone E-mail:

Address of Record:

Contractor Performed as: |_|Prime Contractor |_|Sub-Contractor

Dollar Amount of contract identified in paragraph 1 above.

Dates of Performance (if current include expiration) ____________________________________

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

Q1. Did the contractor provide CBOC services to your agency / organization? (Y/N)___________

Q2. If no, please provide a short description of the type of services the Contractor provided including the number of FTE and/or number of patients served.

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 High Confidence, Confidence or No Confidence, please provide additional information in the appropriate block or in the remarks section of this form.

High Confidence (Purple). Performance record provides virtually no doubt that the Offeror successfully performed the required effort.

Confidence (Green). Performance record indicates the Offeror was able to successfully perform the required effort

No Confidence (Red). Performance record provides extreme doubt that the Offeror successfully performed the required effort.

“U” = Unknown Confidence = The Offeror has no relevant performance record

Please write in “not applicable” or “neutral” if unable to rate a certain question. 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?

U

Q2. How successful was the Contractor in filling all staffing and clinical service requirements?

U

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

U

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

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?

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

Q8. Additional Comments pertaining to contractor performance:

Printed Name & Signature of Evaluator

Date

6. Thank you for your time. Please return completed questionnaire to Marisela Galarza, Contracting Officer, Marisela.galarza@va.gov .

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