36C10X20R0019-005.docx

Past Performance Questionnaire Department of Veterans Affairs: 36C10X20R0019

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INFORMATION REQUEST: PAST PERFORMANCE

This office is currently in the process of awarding a Fixed-Price Contract. [CONTRACTOR NAME] has provided your name and organization as a reference regarding [CONTRACTOR NAME]’s record of past performance under Contract No. [CONTRACT NO.]

[ ] Contract identified above has an Official CPARS Report Filed that can be located in the PPIRS System (if checked above, stop here and submit as part of Volume II)

PAST PERFORMANCE QUESTIONNAIRE

Quoter’s Name:

Request for Quote: VA Office of Healthcare Transformation High Reliability Organization Support BPA

Name of Person Completing the Evaluation:

Please rate the quoter 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

Overall satisfaction with the quoter’s performance. Would you (the reference) choose to work with this quoter again?

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

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

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

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

1. 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.

1. 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.

1. Based on the quoter’s overall performance, would you award them another contract? |_| Yes |_| No If No, please explain.

1. Have you discussed any adverse past performance problems with the quoter and given them an opportunity to comment? |_| Yes |_| No Please explain.

1. Do you file past performance information in a database that the Contracting Officer may search? |_| Yes |_| No Please explain.

1. If the contract had options, were those options exercised? |_| Yes |_| No Please explain.

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

1. What was the dollar value of the contract performed by the quoter?

1. Provide a brief description of the services provided by the quoter for this contract.

Please attach any past performance database reports or other material you deem appropriate to a full understanding of the quoter’s past performance by the evaluator.