36C10X18R0133-A00007002.pdf

PAST PERFORMANCE QUESTIONNAIRE

Solicitation: 36C10X18R0133, Medical Disability Exams under P.L. 104-275 US Department of Veterans Affairs

Completed Questionnaires shall be sent to Stephen.Nickles@va.gov (Contracting Officer) not later than the solicitation close date.

Contractor’s Name: ______________________________________________________________________

Name of Person Completing the Evaluation: __________________________________________________

Telephone: _____________________________ E-Mail: _________________________________________

Title_____________________________Company/Organization: __________________________________

Contract # / Location of Services Provided (City, State, and Zip code): ______________________________

Please rate the contractor in each of the following areas. Note: there is room for comments where you deem remarks would be helpful to our evaluation.

• Not Applicable: N/A

• 1: Performance clearly below the contract performance standard or requirement

• 2: Performance occasionally does not meet minimum contract performance standard or requirement

• 3: Performance that meets the minimum contract performance standard or requirement

• 4: Performance that meets and occasionally exceeds the contract performance standard or requirement

• 5: Performance that almost always exceeds the contract performance standard or requirement

1. Overall quality/satisfaction N/A 1 2 3 4 5

Overall satisfaction with the Contractor’s performance.

2. Delivery performance N/A 1 2 3 4 5

Delivery performance includes delivery consistency, on time performance, and flexibility in responding to emerging issues and implementing required solutions.

3. Satisfaction with the quality of service delivered N/A 1 2 3 4 5

Rate the effectiveness and applicability of the plans and strategies delivered and the actual implementation of those.

mailto:Khurram.Shaikh@va.gov mailto:Stephen.Nickles@va.gov

Solicitation: 36C10X18R0133 Medical Disability Exams under P.L. 104-275 US Department of Veterans Affairs

4. Satisfaction with problem resolution N/A 1 2 3 4 5

This includes the Contractor’s ability to solve problems, the speed in which they handle problems, and their effective delivery of resolutions.

5. Satisfaction with the quality of contractor personnel N/A 1 2 3 4 5

Rate the quality of the contractor’s staff in executing the project work scope.

6. Have you issued a cure notice, show cause notice, suspension of progress payments or other letters directing the correction of a performance problem in the past 3 years?

Yes No If Yes, please explain.

7. Have you terminated this contractor for default within the past 3 years, or are there any pending termination actions? Yes No If Yes, please explain.

8. Based on the contractor’s overall performance, would you award them another contract?

Yes No If No, please explain.

9. Have you discussed any adverse past performance problems with the Contractors and given them an opportunity to comment? Yes No If yes, please explain.

10. Do you file past performance information in a database that the Contracting Officer may search?

Yes No Please explain.

Solicitation: 36C10X18R0133 Medical Disability Exams under P.L. 104-275 US Department of Veterans Affairs

11. If the contract had options, were those options exercised? Yes No Please explain.

12. What was the contract period of performance (i.e., when were services provided)?

13. What was the dollar value of the contract performed by the Contractor?

14. Provide a brief description of the services provided by the Contractor for this contract.

Please attach any past performance database reports or other material you deem appropriate to a full understanding of the contractor’s past performance by the evaluator. Please provide information on any adverse performance by the contractor and the corrective actions taken.