S02 EXHIBIT C Past Performance Questionnaire.pdf

EXHIBIT E – PAST PER FORMANCE QUESTIONNAIRE

SAMPLE TRANSMITTAL LETTER

Your Company Letterhead

Date: _________________

To: ______________________________________

We have listed your firm as a reference for the work we have performed for you as listed below.

Our firm has submitted a proposal under a project advertised by the Department of Veterans

Affairs- Providence VA Medical Center, 830 Chalkstone Ave., Providence RI 02908. In accordance with Federal Acquisition Regulations (FAR), they will evaluate our firm's past performance. Your candid response to the attached questionnaire will assist the evaluation team in this process. We understand that you have a busy schedule and your participation in this evaluation is greatly appreciated. Please complete the enclosed questionnaire as thoroughly as possible. Space is provided for comments. Understand that while the responses to this questionnaire may be released to the offeror, FAR 15.306 (e)(4) prohibits the release of the names of the persons providing the responses. Complete confidentiality will be maintained. Only one response from each office is required.

Please send your completed questionnaire to the following email address TBD. Do not return them to our company.

email to: Kathleen.Mills@va.gov

If you have questions regarding the attached questionnaire, or require assistance, please contact

Kathleen Mills at the above email address. Thank you for your assistance

Please be advised that “E-Mail” is the preferred method of receiving the requested information.

mailto:Kathleen.Mills@va.gov

Department of Veterans Affairs VA Medical Center Providence, RI 02908

PAST PERFORMANCE QUESTIONNAIRE FOR: 36C24124R0065 Renovate and Upgrade Angio

OR Suite, VAMC Providence, RI

INSTRUCTIONS TO OFFEROR

Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and submit it according to the instructions, below.

Company Name Street

Address

Point of Contact

(POC)

City

POC Phone Number State

Reference Project

Title Zip Code

Contract Period of

Performance (start to finish):

Email

Contract Number

Contract

Dollar

Value

Description of Work

Role of Contractor on This Project

(check appropriate box)

Prime Contractor Sub-contractor Key Personnel

INSTRUCTIONS TO REFERENCE CONTACT

The contractor named above is submitting a proposal for a United States Department of Veterans Affairs contract, and has sent this form to you as a past performance reference contact. Please complete the following pages in full (all areas shaded in light yellow, below). Once completed, please send the form directly to the email below:

Email address: Kathleen.Mills@va.gov

Please return the completed form ASAP, but no later than 4:30 pm local time, Date TBD

If you have any questions, please contact the Contract Specialist: Kimberly.Gomez@va.gov

SOURCE SELECTION SENSITIVE WHEN COMPLETED*****NOT TO BE RELEASED OUTSIDE

GOVERNMENT CHANNELS***** RETURN THIS PAGE WITH QUESTIONAIRE

mailto:Kathleen.Mills@va.gov

RESPONDENT INFORMATION [completed by Reference Contact]

Company Name Street

Address

POC Name City

Phone Number State

Email Zip Code

PERFORMANCE INFORMATION: Choose the number on the scale of 0 (Neutral) to

5 (Exceptional) that most accurately describes the contractor’s performance or situation.

PLEASE PROVIDE AN EXPLANATION FOR THE OVERALL RATING in the

Remarks section, below.

0 1 2 3 4 5

NEUTRAL UNACCEPTABLE MARGINAL ACCEPTABLE VERY GOOD OUTSTANDING

No record of past performance, or not applicable or the record is inconclusive.

Performance did not meet most contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective.

Performance did not meet some contractual requirements.

There were problems, some of a serious nature, for which corrective action was only marginally effective.

Performance met most contractual requirements.

There were some minor problems and corrective actions taken by the contractor were satisfactory.

Performance met all contract requirements and exceeded some to the government’s benefit. There were a few minor problems, which the contractor resolved in a timely, effective manner.

Performance exceeded all contract requirements. There were no problems.

QUALITY – MANAGEMENT & WORKMANSHIP

1.

How well did the Offeror utilize quality control process that ensured conformance to scope and quality requirements?

2.

Demonstrated ability to hire, maintain, and replace, if necessary, qualified construction personnel during the contract period.

3.

Provided and followed approved quality control plan and/or inspection procedures to meet contract requirements.

4.

Corrected deficiencies in timely manner and pursuant to their quality control procedures.

5.

Submittals clearly identified the proposed item IAW the specifications and drawings.

6. Suggested alternative approaches to problems.

TIMELINESS AND ADHERENCE TO SCHEDULE

7.

Contractor provided timely notices of possible delays/schedule revisions.

REMARKS:

8.

Timeliness in submitting submittals and reports and responding to agency inquiries, RFP's, etc.

9. Developed realistic and met approved progress schedules.

BUSINESS PRACTICES/CUSTOMER RELATIONSHIP AND ABILITY TO PERFORM

10.

Displayed initiative to solve problems.

11.

How well did the contractor work independent of Government guidance, oversight and assistance?

12.

Subcontractors / tradesmen were adequately managed and coordinated. Explain any subcontracting issues (positive or negative) that impacted the performance of your contract(s).

13.

Contractor independently coordinated with state and city permitting/environmental agencies, public safety departments, and public utility companies.

14.

For contract changes, contractor provided timely and realistic change order proposals.

COMPLIANCE & SAFETY

15.

Reports (i.e., daily, test, logs) / records were submitted completely and accurately satisfy the requirement.

16.

Applicable to Federal Contracts –Contractor complied with applicable

Federal Laws and Regulations such as Construction Wage Rate

Requirements – timely payrolls and compliance; Drug-Free

Workplace; Environmental Regulations and Use of Recovered

Materials; Executive Order 13101 Greening the Government.

17.

Contractor’s safety program was in compliance with federal regulations. Contractor implemented and followed their safety plan and ran a “safe jobsite”.

INFECTION CONTROL

18.

Contractor had an Infection Control Process in place and complied with agency Infection Control Requirements.

OVERALL CUSTOMER SATISFACTION

19. Demonstrated reasonableness in modifications cost proposal.

20.

Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.”

YES NO

21.

Would you award another contract to this contractor? If not, please explain in “remarks.”

YES NO

OVERALL PERFORMANCE RATING:

REMARKS (Please use as much space as is needed – the box will expand as you type).

I hereby certify that the information that I have reported above is accurate to the best of my knowledge.

Printed Name

E-mail address

Business Title Signature Date