Past Performance Questionnaire Fillable.pdf
PDF 182 KB Posted
- Attached to
- V301--DECOMMISSIONING BRICK CLINIC MOVE REQUEST
- Solicitation number
- 36C24224Q1015
About this file
This document is a Past Performance Questionnaire that is part of a federal contract opportunity. The Questionnaire is to be completed by the Respondent, who has significant familiarity with the referenced contract, and provides an evaluation of the Offeror's past performance on that contract. The evaluation covers the Offeror's quality of service, business relations, and customer satisfaction. The completed Questionnaire must be returned to the VA Contracting Office prior to the due date for receipt of proposals for the associated federal contract opportunity.
The related federal contract opportunity is for a contractor to provide labor, transportation, materials, equipment, and supervision to disassemble, relocate, store, or discard furniture and medical equipment from the VA New Jersey Health Care System's Community Based Outpatient Clinics. The contractor will move the items to temperature-controlled and non-temperature-controlled storage units, with the ability to later move the items from storage to the VA Medical Facility as needed. A site visit will be conducted prior to contract performance.
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PAST PERFORMANCE QUESTIONNAIRE
TITLE:
OFFER / QUESTIONNAIRE DUE DATE:
SECTION I: OFFERORS: COMPLETE requested information (Section I) and
PROVIDE the questionnaire to the appropriate Respondent for each source of Past Performance
Information mentioned in your Offer. The Respondent must have significant familiarity with the selected contract or subcontract in order to provide informed answers and comments about various aspects of the past performance.
NAME OF OFFEROR _____________________________________________________
NAME OF PAST PERFORMANCE SOURCE _________________________________
CONTRACT NUMBER and DATES OF SERVICE _____________________________
DESCRIPTION OF SERVICE ______________________________________________
TOTAL AWARDED PRICE ________________________________________________
SECTION II: RESPONDENT(S): COMPLETE the requested information (Section II) concerning the past performance of the above named Offeror relative to the referenced contract effort.
NAME OF RESPONDENT _________________________________________________
TITLE/POSITION ________________________________________________________
SIGNATURE ____________________________________________________________
(A) QUALITY OF SERVICE
1. Did the contractor comply with all contract requirements? ____Yes____No
Comments: ______________________________________________________________
2. With regard to timeliness of performance, were turnaround times of the contract met (i.e.
completion of administrative requirements, task orders, milestones, production and delivery requirements?) ____Yes ____No
Comments: ______________________________________________________________
3. Was the contractor's work found to be accurate and technically/clinically sound?
____Yes____ No
Comments: ______________________________________________________________
4. How would you rate the quality of the contractor's end products / services furnished under this contract?
_____Outstanding _____Good_____ Acceptable ____ Unacceptable
Comments: ______________________________________________________________
5. How would you rate the quality of the contractor's customer service furnished under this contract?
____Outstanding _____Good_____ Acceptable ____ Unacceptable
Comments: ______________________________________________________________
(B) BUSINESS RELATIONS
6. Was contract Management efficient and responsive?
___Always ___Most of the time ___Sometimes ___Never
7. Did the contractor exhibit effective communication(s)?
___Always ___Most of the time ___Sometimes ___Never
8. Did the contractor exhibit reasonable and cooperative behavior?
___Always ___Most of the time ___Sometimes ___Never
9. Was the contractor flexible?
___Always ___Most of the time ___Sometimes ___Never
10. Did the contractor recommend effective solutions to problems?
___Always ___Most of the time ___Sometimes ___Never
11. Did the contractor exhibit a business-like concern for the interests of your Agency or
Business:
___Always ___Most of the time ___Sometimes ___Never
12. How would you rate the contractor in the area of business relations generally?
____Outstanding _____Good_____ Acceptable ____ Unacceptable
Comments on questions 6 through 11 above: ___________________________________
(C) CUSTOMER SATISFACTION
13. How would you rate the contractor on the basis of customer (end-user) satisfaction?
____Outstanding _____Good_____ Acceptable ____ Unacceptable
14. Would you select this firm again?
____Yes ____No
Comments: ______________________________________________________________
End of Section II
SECTION III: COMPLETED FORM MUST BE RETURNED TO THE VA
CONTRACTING OFFICE PRIOR TO THE DUE DATE FOR RECEIPT
OF PROPOSALS . THE OFFEROR MAY SUBMIT THE
COMPLETED QUESTIONNAIRE ALONG WITH HIS/HER PROPOSAL; OR, THE
RESPONDENT PROVIDING THE PERFORMANCE INFORMATION HEREIN MAY
FORWARD THE COMPLETED FORM DIRECTLY TO THE CONTRACTING OFFICE,
no later than at . IN ALL CASES, THE COMPLETED PAST
PERFORMANCE REFERENCES MUST REACH THE CONTRACTING OFFICE BY THE
DATE AND TIME OFFERS ARE DUE. THE GOVERNMENT BEARS NO
RESPONSIBILITY TO ASSURE QUESTIONNAIRES ARE PROPERLY RECEIVED.
POC:
Contract Specialist
NCO 02
Email:
mailto:Eric.Santoyo@va.gov
| NAME OF OFFEROR: |
| NAME OF PAST PERFORMANCE SOURCE: |
| CONTRACT NUMBER and DATES OF SERVICE: |
| DESCRIPTION OF SERVICE: |
| TOTAL AWARDED PRICE: |
| NAME OF RESPONDENT: |
| TITLEPOSITION: |
| 1 Did the contractor comply with all contract requirements: |
| Yes: |
| Comments: |
| requirements: |
| Yes_2: |
| Comments_2: |
| Yes_3: |
| Comments_3: |
| No: |
| 4 How would you rate the quality of the contractors end products services furnished under this: |
| contract: |
| Good: |
| Acceptable: |
| Outstanding: |
| Comments_4: |
| 5 How would you rate the quality of the contractors customer service furnished under this: |
| contract_2: |
| Good_2: |
| Acceptable_2: |
| Outstanding_2: |
| Comments_5: |
| 6 Was contract Management efficient and responsive: |
| Most of the time: |
| Sometimes: |
| Never: |
| 7 Did the contractor exhibit effective communications: |
| Most of the time_2: |
| Sometimes_2: |
| Never_2: |
| 8 Did the contractor exhibit reasonable and cooperative behavior: |
| Most of the time_3: |
| Sometimes_3: |
| Never_3: |
| 9 Was the contractor flexible: |
| Most of the time_4: |
| Sometimes_4: |
| Never_4: |
| 10 Did the contractor recommend effective solutions to problems: |
| Most of the time_5: |
| Sometimes_5: |
| Never_5: |
| 11 Did the contractor exhibit a businesslike concern for the interests of your Agency or: |
| Business: |
| Sometimes_6: |
| Never_6: |
| 12 How would you rate the contractor in the area of business relations generally: |
| Good_3: |
| undefined: |
| Unacceptable: |
| Acceptable_3: |
| Comments on questions 6 through 11 above: |
| Outstanding_3: |
| Good_4: |
| Acceptable_4: |
| Unacceptable_2: |
| Yes_4: |
| No_2: |
| Comments_6: |
| Text1: |
| Text2: |
| Text3: |
| Text4: |
| Text5: |
| Text6: |
| Text7: |
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