36C10F19R0010-012.docx

Attachment 3 – Past Performance Questionnaire

PERFORMANCE QUESTIONNAIRE

Your assistance is requested in support of a source selection.

Please complete this Questionnaire and mail or send via email to: Jeff Gerbensky (Jeffrey.gerbensky@va.gov)

Office of Construction and Facilities Management 1425 Tri State Parkway, Suite 140 Gurnee, IL 60031 Desired Response Date: NLT noon 7/1/2019

When complete, the information on this form is SOURCE SELECTION SENSITIVE INFORMATION (41 U.S.C. 423) and shall be protected accordingly.

TO BE COMPLETED BY OFFEROR

1a. CONTRACTOR NAME & ADDRESS:

2. CONTRACT NO.:

3. CONTRACT AWARD DATE:

4. COMPLETION DATE:

5. CONTRACT VALUE (with options): $

1b. NAME OF PRIME CONTRACTOR (If this questionnaire is for a team member)

6. TYPE OF CONTRACT:

7. PROJECT TITLE, LOCATION, AND DESCRIPTION (AND TOTAL CONSTRUCTION VALUE AT PROJECT COMPLETION):

Please add a continuation page if additional space necessary.

TO BE COMPLETED BY EVALUATING ORGANIZATION REPRESENTATIVE

8. EVALUATION: a. EVALUATOR'S NAME, POSITION (Project Manager/ COR/ Other) AND ORGANIZATION:

b. EVALUATOR'S PHONE NUMBER: c. MONTHS PERFORMANCE MONITORED BY EVALUATOR:

Please circle the response code for each topic (A – G) that best reflects your experience with this contractor.

A. Quality of Products and Services - Assess the contractor’s conformance to contract requirements, specifications, and standards of good workmanship (e.g., technical, professional, environmental, or safety and health standards).

E G S M U N/O

B. Performance – Assess the contractor’s performance as the General Contractor or Architect/Engineer (as appropriate) for the project.

E G S M U N/O

C. Schedule – Assess the timeliness of contractor against the schedule of activities.

E G S M U N/O

D. Technical Requirements – Assess the contractor’s ability to fulfill the technical requirements of the contract.

E G S M U N/O

E. Cost Control – Assess the contractor’s ability to manage the contract budget and control costs.

E G S M U N/O

F. Customer Satisfaction – Assess the contractor’s responsiveness to customer concerns and “user friendliness”.

E G S M U N/O

G. Overall Assessment.

E G S M U N/O