ATTACHMENT G - PAST PERFORMANCE QUESTIONAIRE - NX EQ SCANNING LASER OPTICAL BIOMETRY SYSTEM.pdf
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- Solicitation number
- 36C10G26R0010
About this file
This is a Past Performance Questionnaire template issued by the Department of Veterans Affairs (VA) Strategic Acquisition Center (SAC) for solicitation 36C10G26R0010 concerning the procurement of NX EQ Scanning Systems Laser Optical Biometry System (Zeiss® IOL Master 700 Brand Name or Equal).
Offerors must submit the questionnaire to each reference cited in their proposal, with a maximum of five references from the past three years. Completed questionnaires must be emailed to Lisa Thompson at Lisa.thompson10@va.gov by May 08, 2026, at 11:59 PM EST. The questionnaire requires references to provide information including contract number, period of performance, total contract value, option exercise status, service/commodity description, and whether show cause orders, stop work orders, or terminations were issued. References rate offerors across four categories—Quality of Service, Cost Control, Timeliness of Performance, and Business Relations—using a three-point rating scale (1: Unsatisfactory, 2: Satisfactory, 3: Excellent), with detailed guidelines provided for each category. The questionnaire also includes an Overall Satisfaction section asking whether the reference would choose to work with the offeror again. References must provide comments supporting their ratings in designated spaces for each evaluation category.
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36C10G26R0010
Attachment G Past Performance Questionnaire
SOLICITATION NO.: 36C10G26R0010
DESCRIPTION: NX EQ SCANNING SYSTEMS LASER OPTICAL BIOMETRY
SYSTEM. – Zeiss® IOL Master 700 Brand Name or Equal
Offerors: Please Send to Each Reference Cited in Submitted Proposal (Maximum of Five References from Past Three Years)
DEPARTMENT OF VETERANS AFFAIRS (VA)
STRATEGIC ACQUISITION CENTER (SAC)
PAST PERFORMANCE QUESTIONNAIRE
TO: Lisa Thompson E-MAIL: Lisa.thompson10@va.gov
VA SAC is currently in the process of awarding a contract for the solicitation described above.
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)
Contract Number: (Insert Applicable Contract Number 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 Lisa.thompson10@va.gov by May 08, 2026, at 11:59 PM EST.
Name of Reference: (Reference Complete These
Sections) Title of Reference:
Phone Number:
E-Mail Address:
Name of Organization:
Contract Period of Performance (Month/Day/Year Begin and End):
Total Contract Value (Base and All Option Years):
Options Exercised on Contract (Yes/No)?
Brief Description of Services/Commodity Provided by Offeror:
Show Cause Order Issued on Contract (Yes/No)?
Stop Work Order Issued on Contract (Yes/No)?
Termination for Convenience, Cause, or Default Issued on Contract (Yes/No)?
Rating Guidelines:
Rating Quality of
Service Cost Control
Timeliness of Performance
Business Relations
1: Unsatisfactory Offeror is not in compliance and has jeopardized achievement of contract objectives
Offeror is unable to manage costs effectively
Offeror delays have jeopardized performance
Responses to inquiries and issues are not effective
2: Satisfactory Minor inefficiencies and errors have been identified
Offeror is usually effective in managing costs
Offeror is usually effective in meeting milestones and delivery schedule
Responses to inquiries and issues is usually effective
3: Excellent Offeror is in compliance with contract requirements and delivers quality services
Offeror is effective in managing costs and submits proper invoices
Offeror is effective in meeting and exceeding milestones and delivery schedule
Responses to inquiries have been effective and/or exceeded expectations and established deadlines
Offeror Evaluation:
Rating (List Number Based on Rating Guidelines Above)
Category Description
Quality of Service
In compliance with contract requirements, submits accurate reports/deliverables, has effective personnel, and has achieved/maintained technical excellence:
Comment from Reference: _______________________
Cost Control Has achieved efficiencies in costs, managed costs effectively, and has submitted timely/accurate invoices with supporting documentation:
Timeliness of Performance
Has met milestones, is reliable, is responsive to technical direction, and has completed milestones on-time or ahead of schedule:
Business Relations
Has maintained effective management of contract, has exhibited reasonable/cooperative behavior, is responsive to contract requirements, is responsive to inquiries/issues, and is proactive about resolving problems:
YES NO Overall Satisfaction
Would you (reference) choose to work with this offeror again?
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