36C24119R0084-005.docx

ATTACHMENT 1 - PAST PERFORMANCE QUESTIONAIRE AND COVER LETTER

36C24119R0047 FIRE PUMP REPLACEMENT PROJECT

Complete one set of letters and forms for each project identified in your response to the requirements outlined in the SF 1442 Section I, Project Experience. Additional space or blank sheets may be added to answer any question.

Transmittal Letter to Accompany Past Performance Questionnaire

FROM: [Insert Company Official Name, Title, and Company Name] SUBJECT: Past Performance Questionnaire for Contract(s):

[Insert Company Name] is currently responding to Department of Veterans Affairs (NCO 1) request for Solicitation 36C24119R0047, Fire Pump Replacement for the replacement of the Fire Pump.

[Insert Company Name] is providing past performance data to NCO 1 relating to our performance on contract [Insert contract name/number] and have identified [Insert name of reference] as the point of contact for this contract.

The request for solicitation 36C24119R0047 instructs that respondents provide customers with the attached questionnaire. Please complete the questionnaire and submit it by directly to the NCO 1 Contracting Office Contracting Officer by March 1, 2019. P{lease submit by email to the Government representative identified below. Please state in the subject line “36C24119R0047 PAST PERFORMANCE QUESTIONNAIRE” If the Past Performance Questionnaire is emailed, DO NOT send a hard copy via mail.

Stacy S. Dion, Contract Specialist VISN 1 Network Contracting Office (NCO1) E-mail: Stacy.Dion@va.gov Phone: 802-296-5105

The information contained in the completed Past Performance Questionnaire is considered sensitive and cannot be released to [Insert Company Name]. Please direct any questions about the acquisition or the attached questionnaire to the VISN 1 NCO point of contact identified above.

Thank you, [Insert Company Official Name and Title]

Company Evaluated:

Company Name: Address:

Telephone: Email address: Point of Contact:

Firm Cage Code: Firm Tax ID Number: Firm DUNS Number:

Project Title:

Description of Project:

Description of Responsibilities:

Contract Number:

Dollar Amount:

Contract Period of Performance:

The company performed as the Prime Contractor/Sub-Contractor/Consultant/Team Member Percent of work performed by Contractor: Other (Please describe)

EVALUATOR INFORMATION:

Evaluator’s Company or Agency Name: Address:

Evaluator’s Name: Title of Evaluator: Telephone: E-mail:

**Evaluator**

A. SEND COMPLETED QUESTIONAIRE (SECTIONS B & C) DIRECTLY TO:

Stacy S. Dion, Contract Specialist VISN 1 Network Contracting Office (NCO1) E-mail: Stacy.Dion@va.gov Phone: 802-296-5105

PERFORMANCE INFORMATION: Choose the appropriate rating that most accurately describes the Company’s. Please provide a narrative of all ratings of Marginal or Unsatisfactory in the area allotted for comments below. Pages may be added as necessary. Please call the Contract Specialist if you have questions regarding this form.

Corrective actions being taken by the contractor appear to be effective or Corrective actions taken were effective.

Section B:

COMPANY NAME: PROJECT NAME:

Contract Period of Performance:

Original Contract Cost:

Final Contract Costs:

Note: Include this information on each page of the questionnaire form to ensure there is no mix up in information among contracts surveyed for respective primes/subs, etc.

Place an “X” in the appropriate column using the definitions matrix on page 4.

Item

FACTORS TO BE RATED

Technical:

Key Personnel:

Schedule:

Safety:

Section C:

CONTRACTOR’S NAME:

PROJECT NAME

Contract Period of Performance:

Note: Include this information on each page of the questionnaire form to ensure there is no mix up in information among contracts surveyed for respective primes/subs, etc.

NARRATIVE SUMMARY (Use this section to explain any rating from the previous page)