36C10G19R0008-012.docx

Attachment 10

DEPARTMENT OF VETERANS AFFAIRS (VA)

STRATEGIC ACQUISITION CENTER (SAC)

PAST PERFORMANCE QUESTIONNAIRE

Past Performance Questionnaire (PPQ)

SOLICITATION NO.: 36C10G19R008

DESCRIPTION: Hospital Beds for In Home Use Offerors: Please Send to Each Reference Cited in Submitted Proposal (Maximum of Five References from Past Three Years)

TO: Contract Specialist, John Tarver E-MAIL: John.Tarver@va.gov

TO: Contracting Officer, Lawrence Toperoff E-MAIL: Lawrence.Toperoff@va.gov VA SAC is currently in the process of awarding a contract for Hospital Beds for In Home Use and Ancillary accessories such as Trapeze Bar and Mount, Pendent, Head/Foot boards, Full, Half and Split Rails, and Mattress. The Offeror identified below has provided your organization’s name as a reference under the contract described below:

Offeror Name:

(Insert Offeror’s Name Here)

Please rate the Offeror in each of the categories on this questionnaire. See “Rating Guidelines” section for detailed description of categories and ratings. There is room for comments where you deem remarks would be helpful to our evaluation (see ‘Comment from Reference’ under “Offeror Evaluation”. Please note that the past performance evaluators for this solicitation may contact you for further details in making a fair assessment of this Offeror’s past performance. Thank you for your organization’s assistance in fairly evaluating Offeror proposals for this solicitation.

Please E-mail Questionnaire to the Contracting Officer and Contract Specialist by September 13, 2019, 4:00 PM EDT

Title of Reference:

Phone Number:

E-Mail Address:

Name of Organization:

Purchase date

Total Purchase Value:

Brief Description of Services/Products Provided by Offeror:

Rating Guidelines:

Offeror Evaluation:

Comment from Reference: _______________________