Attachment 5: Past Performance Questionnaire

Attachment. D.5

PAST PERFORMANCE QUESTIONNAIRE

Request for Quote - 36C24827Q0013
Perfusionist/Autotransfusionist
Services
1. Background: The Malcolm Randal VA Medical Center has an ongoing requirement for Perfusionist/ Autotransfusionist Services. The vendor has identified you as a reference to validate the their past performance. This question is concerns pass or current contractors/agreements for which you have personal knowledge.
2. Instruction: Please complete this questionnaire based on the following guidance. Please take the time to answer the questions to the best of your knowledge. Circle the responses that best describe the company’s performance and write in a narrative explanation for you answer. Use a N/A rating to indicate that you have no performance information for that particular area, or if the question does not apply to you. Each question has space for your comments. If more space is needed, please attach additional sheets to the end of the questionnaire and reference to respective questions. Handwritten (ink) responses are sufficient.

Please complete the following questionnaire to assist our evaluation of the company's past performance and return no later than the date the contractor advises. Please return to Peter Bedard email at [email protected] .
Title/Description of Proposed Project:
Please evaluate the past performance using only the following ratings without variation. If the ratings is Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form
“O” = Outstanding
=
Performance greatly exceeded the contract requirements
“A” = Above Average =
Performance exceeded the contract requirements
“S” = Satisfactory
=
Performance met the contract requirements
“M = Marginal
=
Performance meet the minimum contract requirements but
some material aspects of the company's performance were less than satisfactory “U” = Unacceptable
=
Performance was poor and/or did not satisfy contract
requirements

CUSTOMER SATISFACTION

1. Company maintain a professional staff.
Outstanding

Above Average

Satisfactory

Marginal

Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

2. Company was responsive to inquiries regarding contract/agreement. Outstanding

Above Average

Satisfactory

Marginal

Unacceptable

BRIEF EXPLANATION OF RATING GIVEN:

3. Company was flexible in responding to urgent requirements. Outstanding

Above Average

Satisfactory

Marginal