VA261-17-R-1281-005.doc

Solicitation VA261-17-R-1281 Air Ambulance Services Attachment 3

Attachment F

Past Performance Questionnaire

Solicitation VA261-17-R-1281 Air Ambulance Services

PAST PERFORMANCE QUESTIONNAIRE

AIR AMBULANCE SERVICES

I. INTRODUCTION:

This questionnaire is designed to collect past performance information on offerors competing for award of a contract for air ambulance services for the VA Pacific Islands Health Care System, Hawaiian Islands. Please complete the enclosed questionnaire and return it directly to Veterans Affairs at your earliest convenience. For assistance with this form or to request an electronic copy please notify the contracting specialist listed below. Handwritten responses will be accepted. If you need more space than provided, please attach additional pages or write on the last page. Please include only relevant information. Responses will be treated as source selection sensitive. Return the questionnaire either by mail, fax or email to the following address:

VA Sierra Pacific Network (VISN 21) Telephone: (916)-923-4507

Attn: Denard M Fobbs Jr (NCO 21) E-mail:

Denard.Fobbs@va.gov 3230 Peacekeeper Way, Bldg. 209

FAX: (916) 923-4554

McClellan CA 95652

II. CUSTOMER/CLIENT IDENTIFICATION:

The following information pertains to the organization and contract information of the customer completing the questionnaire:

Your company or agency name: ___________________________________________________ Name of contractor being evaluated: ________________________________________________

Your contract number: __________________ Total value of your contract: $ _____________________ Performance Period: Basic Period: ____________________ Option Periods: _____________________

Brief description of services provided: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

III. EVALUATOR INFORMATION:

The following information pertains to the person completing this questionnaire.

Name/Title: __________________________________________________________________________

(e.g. Physician, Technician, Contracting Officer, etc.)

Organization: _________________________________________________________________________

Phone Number: _______________________________________________________________________

IV.

Explanation of codes:

In Section V below of this questionnaire we ask 22 questions regarding your contractor’s performance. Please use the following ratings when rating the contractor’s performance:

CODE

PERFORMANCE RATINGS

V.

QUESTIONS CONCERNING PAST PEFORMANCE:

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.

1. Describe in detail the type of air transportation services provided to your company (types of services/duties, how often they performed).

2. In what type of setting did the vendor perform (i.e. healthcare facility, office)? _____________________

3. Length of the Service (Provide dates): _____________________________________________________

Q2. How timely was the contractor’s performance?

E V S M U N

Q3. How well did the contractor comply with the labor and safety standards?

E V S M U N

Q4. Rate the effectiveness of the contractor’s management of the contract?

E V S M U N

Q5. Rate the contractor’s handling of staff integrity issues.

E V S M U N

Q6. Rate the contractor’s personnel management practices.

E V S M U N

Q7. Quality Control: Rate the overall quality of contractor’s work.

E V S M U N

T1. To what extent did the contractor meet performance schedule?

E V S M U N

T2. What extent was contractor flexible in responding to changing needs?

E V S M U N

T3. To what extent was the contractor reliable?

E V S M U N

T4. To what extent was the Contractor responsive to technical directions?

E V S M U N

T5. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, explain.

Yes No

C1. Would you award another contract to this contractor? If no, explain.

Yes No

C2. Was the customer satisfied with the end product? If no, explain.

Yes No

C3. To what extent did contractor notify you of problems of potential issues?

E V S M U N

Evaluator’s Additional Remarks regarding Air Ambulance Services:

Signature of Evaluator: Date of Evaluation:

Print Name of Evaluator:

Source Selection Information – See FAR 3.104

Source Selection Information – See FAR 3.104