36C10G19R0003-023.docx

VA119-15-R-0025

Attachment 3

PAST PERFORMANCE ASSESSMENT QUESTIONNAIRE

Please provide your candid responses. The information that you provide will be used in the awarding of federal contracts. Therefore, it is important that your information be as factual, accurate and complete as possible to preclude the need for follow-up by the evaluators. If you do not have knowledge of or experience with the company in question, please forward this Questionnaire to the person who does. Thank you.

PART I. (To be completed by the Offeror)

A. CONTRACT IDENTIFICATION

Contractor/Company Name/Division:

Address:

Program Identification/Title:

Contract Number:

Contract Type:

Prime Contractor Name (if different from the contractor name cited above):

Contract Award Date:

Forecasted or Actual Contract Completion Date:

Nature of the Contractual Effort or Items Purchased:

B. IDENTIFICATION OF OFFEROR’S REPRESENTATIVE

Prime Offeror:

POC Name:

POC Title:

Date:

POC Telephone Number:

POC FAX Number:

POC Address:

E-mail Address:

PART II. EVALUATION (TO BE COMPLETED BY POINT OF CONTACT – RESPONDENT)

A. Compliance of Products, Services, Documents, and Related Deliverables to Specification Requirements and Standards of Good Workmanship.

· Exceeds Contractual Requirements (Explanation must be provided in Comments field below)

· Meets Contractual Requirements

· Failed to Meet Contractual Requirements (Explanation must be provided in Comments field below)

Comments:

B. Effectiveness of Project Management (to include use and control of subcontractors).

· Exceptional (Explanation must be provided in Comments field below)

· Satisfactory

· Unsatisfactory (Explanation must be provided in Comments field below)

C. If this was a performance based contract, how well did the contractor perform against the contract metrics?

· Unsatisfactory (Explanation must be provided in Comments field below)

· Not a performance based contract

D. Rate the contractor’s ability to identify and mitigate risks.

E. Rate the contractor’s ability to manage complex projects at multiple, geographical dispersed sites, if applicable.

· Unsatisfactory (Explanation must be provided in Comments field below)

· Not Applicable

F. Timeliness of Performance for Services and Product Deliverables, including the Administrative Aspects of Performance.

· Exceeds Contractual Requirements (Explanation must be provided in Comments field below)

· Meets Contractual Requirements

· Failed to Meet Contractual Requirements (Explanation must be provided in Comments field below)

G. Describe how the work under this contract is related to experience cited in number of end users and coverage requirements and devices provided.

· Satisfactory

H. Commitment to Customer Satisfaction and Business-like Concern for its Customers’ Interest.

I. Overall Satisfaction.

· Extremely Satisfactory (Explanation must be provided in Comments field below)

J. General Comments. Provide any other relevant performance information.

Are you aware of other relevant past efforts by this company?

If yes, please provide the name and telephone number of a point of contact:

K. Other Information Sources. Please provide the following information:

Organization:

Name:

Title:

Date:

Telephone Number:

Address:

Fax Number:

E-mail Address:

L. Respondent Identification. Please provide the following information:

Organization:

Name:

Title:

Date:

Telephone Number:

Address:

Fax Number:

E-mail Address:

PART III. RETURN INFORMATION

Please return this completed Past Performance Questionnaire AS AN ATTACHMENT via e-mail to lance.belcher@va.gov and fawn.ivey@va.gov. The subject line of the email must read: MSPV Past Performance Questionnaire Ref Solicitation # VA119-15-R-0025 in order for the email to be successfully transmitted and received. The subject line should be in black type and is case sensitive.

Thank you for your assistance.