ATTACHMENT D Past Performance Questionnaire Home Oxygen

ATTACHMENT D – PAST PERFORMANCE QUESTIONNAIRE

GENERAL INFORMATION (Completed by Offeror):

Scope of Services (e.g., geographic coverage area, frequency of services, etc.): REFERENCE INFORMATION (Completed by Evaluator):

REFERENCE INSTRUCTIONS: The Department of Veterans Affairs, New York/New Jersey VA Health Care Network (VISN 2) is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. The intent of this questionnaire is to evaluate the Offeror’s performance regarding Home Oxygen Services. Your comments are considered Source Selection Sensitive; therefore, you are advised that Federal Acquisition Regulation (FAR) 15.506 prohibits the release of the names of the individuals providing reference information about the Offeror’s past performance. Please complete the survey below and return to Corey Swinton, Contract Specialist, at [email protected] no later than 10/01/2026. Please evaluate the Offeror’s past performance using the following rating system without variation. If a rating of Marginal or Unsatisfactory is selected, provide additional information in the appropriate block or in the remarks section of this form.

UNSATISFACTORY

MARGINAL

SATISFACTORY

VERY GOOD

EXCEPTIONAL

NEUTRAL

Performance did not meet most contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective. Performance did not meet some contractual requirements. There were problems, some of a serious nature, for which corrective action was only marginally effective. Performance met contractual requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory. Performance met all contract requirements and exceeded some to your benefit. There were a few minor problems, which the contractor resolved in a timely, effective manner. Performance met all contractual requirements and exceeded many to your benefit. Problems, if any, were negligible and were resolved in a timely, highly effective manner. No record of past performance or record is inconclusive.

ID #
Question
Select Rating
Q1.
To what extent did the Contractor comply with contract requirements?

U/ M/ S/ V/ E/ N

Q1. Remarks

Q2.
To what extent did the Contractor display technical expertise?

U/ M/ S/ V/ E/ N

Q2. Remarks

Q3.
To what extent did the Contractor comply with Joint Commission standards?

U/ M/ S/ V/ E/ N

Q3. Remarks

Q4.
Rate the effectiveness of the Contractor’s management of the contract.