11 - Past Performance Questionaire Form for VA REV_ Nov 23.pdf

Past Performance List of References

Past Performance List of References Form for VA (REV. 11/23)

Solicitation Information

RLP No.: 36C10F25R0024

Offers Due By (Date/Time):

VA Contracting Officer (Name/Email):

VA Broker (Name/Email):

Offeror Entity Name:

PAST PERFORMANCE LIST OF REFERENCES

In reference to column PPQ below, check the appropriate box (see RLP, Section 4.04, for submission instructions):

A. Select A if VA Contract, Offeror using a previously completed PPQ B. Select B if VA Contract, Offeror submitted a PPQ request to the contract reference; include date of submission C. Select C if Non-VA Contract

Contract Reference

No.

Past Performance Contractor Entity Past Performance Reference PPQ Date PPQ Submitted to

Reference Entity Name UEI No. Name/Title Phone/Email

A B C

Past Performance Questionnaire Form for VA

Past Performance Questionnaire Form for VA (REV. 11/23) 1

PART I. PAST PERFORMANCE QUESTIONAIRE (PPQ) COVER PAGE

RLP No.:

Offeror Entity Name:

1. CONTRATOR INFORMATION

Project Reference No.:

Entity Name:

Contact Name: Entity Address:

Contact Phone/Email: UEI No.:

2. GENERAL WORK INFORMATION

Work Performed For:

Customer Name (if Non-VA):

Work Performed As:

Percentage (%) of Work Performed:

3. CONTRACT DETAILS

Type of Contract:

If Other, Explain:

Contract No.: Place of Performance:

Contract Award Date: Price at Award:

Contract Completion Date: Price at Completion:

4. REFERENCES

Contracting Officer/Signature Authority

Resident Engineer/Technical Representative

Name:

Title:

Phone:

Email:

Name:

Title:

Phone:

Email:

5. PROJECT DESCRIPTION

(Attach additional pages if needed)

Project Size:

Type of Facility/Work:

If Other, Explain:

Detailed Description of the Work Performed/Explanation of Relevancy to RLP Requirements:

Key Personnel Names/Roles (Indicate if Assigned to Current Solicitation):

Major Subcontractor(s) Names/Roles:

6. OFFEROR CERTIFICATION OF PART I

I certify that the information provided in this PPQ is accurate and complete.

Signature

Date

Past Performance Questionnaire Form for VA (REV. 11/23) 2

PART II (A). PAST PERFORMANCE QUESTIONAIRE INFORMATION

Requested by:

Completed by: Date Completed:

1. CONTRACT DETAILS

Contract No.:

All contract details and description of work performed outlined in Part I of this PPQ is accurate:

If not, please explain:

(additional space for comments is provided on page 4)

2. REFERENCES

Contracting Officer/Signature Authority

Resident Engineer/Technical Representative

Name:

Title:

Phone:

Email:

Name:

Title:

Phone:

Email:

Describe Your Role in the Project:

3. REFERENCE CERTIFICATION OF PART II

I certify that the information provided in this PPQ is accurate and complete.

Signature

Date

Use the following adjective ratings and definitions in your evaluation of the Contractor’s performance.

RATING DEFINITION NOTE

(E) Exceptional Performance meets contractual requirements and exceeds many to the Government benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor was highly effective.

An Exceptional rating is appropriate when the Contractor successfully performed multiple significant events that were of benefit to the Government. A singular benefit, however, could be of such magnitude that it alone constitutes an Exceptional rating. Also, there should have been NO significant weaknesses identified.

(VG) Very Good Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

A Very Good rating is appropriate when the Contractor successfully performed a significant event that was a benefit to the Government. There should have been no significant weaknesses identified.

(S) Satisfactory Performance meets minimum contractual requirements.

The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

A Satisfactory rating is appropriate when there were only minor problems, or major problems that the contractor recovered from without impact to the contract. There should have been NO significant weaknesses identified. Per VA policy, a fundamental principle of assigning ratings is that contractors will not be assessed a rating lower than Satisfactory solely for not performing beyond the requirements of the contract.

(M) Marginal Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor's proposed actions appear only marginally effective or were not fully implemented.

A Marginal is appropriate when a significant event occurred that the contractor had trouble overcoming which impacted the Government.

(U) Unsatisfactory Performance does not meet most contractual requirements and recovery is not likely in a timely manner.

The contractual performance of the element or sub-element contains serious problem(s) for which the contractor's corrective actions appear or were ineffective.

An Unsatisfactory rating is appropriate when multiple significant events occurred that the contractor had trouble overcoming and which impacted the Government. A singular problem, however, could be of such serious magnitude that it alone constitutes an unsatisfactory rating.

(N/A) Not Applicable No information or did not apply to your contract Rating will be neither positive nor negative.

Past Performance Questionnaire Form for VA (REV. 11/23) 3

PART II. PAST PERFORMANCE QUESTIONAIRE EVALUATION

Select the adjective rating that best reflects your evaluation of the contractor’s performance unless otherwise indicated.

1. QUALITY E VG S M U N

(a) Quality of building design, construction, workmanship, materials used, interior spaces, and overall appearance

(b) Ability to meet quality standards specified for technical performance

(c) Timeliness/effectiveness of contract problem resolution without extensive customer guidance

(d) Adequacy/effectiveness of quality control program and adherence to quality assurance requirements, without adverse effect on performance

2. SCHEDULE/TIMELINESS OF PERFORMANCE E VG S M U N

(a) Compliance with contract delivery/completion schedules including significant milestones

If rating of M or U, please explain:

(b) Rate the contractor’s use of available resources to accomplish tasks identified in the contract

(c) Rate your satisfaction with the contractor’s ability to respond to questions and/or comments in a timely manner

3. CUSTOMER SATISFACTION E VG S M U N

(a) To what extent were the end users satisfied with the project

(b) To what extent was the contractor reasonable and cooperative in dealing with your staff to include the ability to successfully resolve disagreements and/or disputes

(c) To what extent was the contractor cooperative, businesslike, and concerned with the interests of the customer

(d) Customers overall satisfaction

4. MANAGEMENT/ PERSONNEL/LABOR E VG S M U N

(a) Effectiveness of management, including management of subcontractors and/or labor force

(b) Ability to hire, apply, and retain a qualified workforce to this effort

(c) Government Information Property Control

(d) Knowledge/expertise demonstrated by contractor key personnel

(e) Government contract requiring a subcontracting plan (complete if the contractor was required to submit and adhere to a small business subcontracting plan)

(f) If applicable, were small business goals met Yes No N/A

(g) Ability to simultaneously manage multiple projects with multiple disciplines

(h) Ability to assimilate and incorporate changes in requirements and/or priority, including planning, execution, and response to Government changes

(i) Effectiveness of overall management and the ability to effectively lead, manage and control the project

5. COST/FINANCIAL MANAGEMENT E VG S M U N

(a) Ability to meet the terms and conditions within the contractually agreed price(s)

(b) Proposed innovative alternative methods/processes that reduced cost, improved maintainability or other factors resulting in savings

(c) Accounting system was adequate for managing and tracking costs Yes No N/A

(d) Was contract was partially or completely terminated for default or convenience, or are there any pending terminations Yes No N/A

If yes, indicate if show cause, cure notices or any default action was issued:

(e) Have there been any indications that the contractor has had any financial problems Yes No N/A

If yes, please explain:

Past Performance Questionnaire Form for VA (REV. 11/23) 4

6. SAFETY/SECURITY E VG S M U N

(a) Ability to maintain an environment of safety, adhere to its approved safety plan, and respond to safety issues to include following the users’ rules, regulations, and requirements

(b) Contractor complied with all general and IT security requirements for the project and personnel security requirements

7. GENERAL E VG S M U N

(a) Ability to successfully respond to emergency and/or surge situations (includes notifying COR, PM or Contracting Officer in a timely manner)

(b) Ability to comply with contractual terms/provisions

If no, please explain:

8. SUMMARY E VG S M U N

(a) In summary, provide an overall rating for the work performed by this contractor

(b) Would you hire or work with this firm again Yes No If no, please explain:

COMMENTS SECTION

Provide a brief narrative addressing specific strengths, weaknesses, deficiencies, or other comments which may assist our office in evaluating performance risk (attach additional pages if necessary).