36C24418R0074-003.docx

PAST PERFORMANCE SURVEY

REFERENCE INSTRUCTIONS: The Department of Veterans Affairs is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation (15.506) prohibits the release of the names of individuals providing reference information about Offeror’s past performance. Survey should be completed by evaluator and returned no later than (insert date) to Stanley.Kwasny@va.gov.

Please evaluate the past performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, please provide additional information in the appropriate block or in the remarks section of this form.

“O” = Outstanding = Performance greatly exceeded the contract requirements

“A” = Above Average = Performance exceeded the contract requirements

“S” = Satisfactory = Performance met the contract requirements

“M” = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory

“U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements

Name of firm being evaluated:

Q1. To what extent did the contractor comply with contract requirements?

O A S M U

Q2. How timely was the contractor’s performance?

O A S M U

Q3. How well did the contractor comply with labor and safety standards?

O A S M U

Q4. Rate the effectiveness of the contractor’s management of the contract.

O A S M U

Q5. Rate the contractor’s handling of staff integrity issues.

O A S M U

Q6. Rate the contractor’s personnel management practices.

O A S M U

Q7. Quality control: Rate the overall quality on the contractors work.

O A S M U

T1. To what extent was contractor able to meet the performance schedule:

O A S M U

T2. What extent was contractor flexible in responding to changing needs?

O A S M U

T3. To what extent was the contractor reliable?

O A S M U

T4. To what extent was the contractor responsive to technical directions?

O A S M U

T5. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, please explain.

Yes No

C1. Would you award another contract to the party being evaluated? If no, please explain:

C2. Was the customer satisfied with the end product? If no, please explain:

C3. To what extent did contractor notify you of problems or potential problems?

O A S M U

Additional Remarks:

Name/Signature of Evaluator:

Company/Organization:

Date