11. Exhibit J - Sample Request for Past Performance and Questionnaire.docx

RLP 36C248-24-R-00040 EXHIBIT J - SAMPLE REQUEST FOR PAST PERFORMANCE AND QUESTIONNAIRE

Date:

From:

To:

Re: Past Performance Questionnaire Our firm is competing for a requirement solicited by the Department of Veterans Affairs (VA). In accordance with Federal Acquisition Regulations (FAR), the evaluation of our firm's past performance will be included in the award evaluation decision to be made by the VA. Your frank and candid response to this questionnaire will assist the evaluation team in this process.

Please note that while the responses of this questionnaire may be released to our firm by the VA, FAR 15.306(e) (4) prohibits the release of the names of the persons providing the responses. Complete confidentiality will be maintained.

This survey should be completed by the individual most knowledgeable of our firm's day-to-day operations and the overall condition of the service rendered. However, that individual is encouraged to supplement their own knowledge of our performance with the judgment of others in your organization. Completed evaluations may be scanned and emailed to javier.correaochoa@va.gov. Completed evaluations must be received no later than close of business on _________________.

If you have any questions regarding this please contact Javier Correa-Ochoa at 786-299-2659 or via email at Javier.correaochoa@va.gov Thank you for your valuable input and assistance.

Signature Contractor Representative Name:

Contractor Company Name:

Contractor Address:

Contract Number:

Date of Award:

Location and Description of Work:

PAST PERFORMANCE QUESTIONNAIRE

1. Contractor Rating:

Please place an “X” on the circle for the rating that best applies to the work performed and provide responses or additional comments accordingly.

Exceptional: Significantly exceeds lease requirements to benefit the owner. Performance in the area indicated was accomplished with few minor problems which were effectively corrected.

Very Good: Meets all lease requirements and exceeds some to benefit of the owner. Performance in the area indicated was accomplished with few minor problems which were effectively corrected.

Satisfactory: Meets all lease requirements. Performance in the area indicated was accomplished with some minor problems which appear to be adequately corrected.

Marginal: Does not meet some lease requirements. Performance in the area indicated reflects a serious problem which has been minimally corrected, if at all.

Unsatisfactory: Does not meet lease requirements and recovery is not likely in a timely or cost-effective manner. Performance in the area indicated contains serious problem(s) which have been ineffectively corrected.

2. Quality of Work

f) How would you rate the contractor's compliance with safety standards?

O Exceptional O Very Good O Satisfactory O Marginal O Unsatisfactory

g) To what extent have maintenance problems occurred (roof leaks, HVAC levels, pest infestations, etc.)?__________________________________________________________________________

h) Would you select this firm again? O YES O NO

i) Additional Comments ____________________________________________________________________________________________________________________________________________________________________

3. Response Timing

a) How would you rate the contractor's timeliness in correcting any deficiencies in regards to maintenance problems (roof leaks, HVAC levels, pest infestations, etc.)?

O Exceptional O Very Good O Satisfactory O Marginal O Unsatisfactory

b) How would you rate the contractor's timeliness in submitting required reports, schedules, and documentation?

O Exceptional O Very Good O Satisfactory O Marginal O Unsatisfactory

c) Additional Comments __________________________________________________________________________________________________________________________________________________________________

4. Cost Control

a) Amount of Original Contract $______________________

b) Were deductions taken for unperformed or defective work?

O Frequently O Rarely O Never

c) How would you rate the contractor's efforts in controlling costs, especially in regards to modifications to the contract?

O Exceptional O Very Good O Satisfactory O Marginal O Unsatisfactory

d) Additional Comments ____________________________________________________________________________________________________________________________________________________________________

5. Business Management

a) How would you rate the contractor's on-site management of personnel and subcontractors?

O Exceptional O Very Good O Satisfactory O Marginal O Unsatisfactory

b) How would you rate the contractor's onsite quality control?

O Exceptional O Very Good O Satisfactory O Marginal O Unsatisfactory

c) How would you rate the contractor's management and coordination of subcontractors?

O Exceptional O Very Good O Satisfactory O Marginal O Unsatisfactory

6. Overall Rating of Contractor

a) What is your overall rating of the contractor 's performance?

O Exceptional O Very Good O Satisfactory O Marginal O Unsatisfactory

b) Additional Comments ____________________________________________________________________________________________________________________________________________________________________ Evaluated by:

Signature:_________________________________________ Date: ____________________ Name of Evaluator :__________________________________________ Title of Evaluator:___________________________________________ Telephone: ________________________________________________ E-mail: ____________________________________________________