Amd 2EXHIBIT E PastPerformanceQuestionnaire.pdf

Department of Veterans Affairs Network Contracting Office 4

1010 Delafield Road Pittsburgh, PA 15215

1 | P a g e

Past Performance Questionnaire for: 36C24422R0041 Construct Women’s Health

Radiology Suite

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 a ccording 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 to the Contracting Officer via postal mail or email directly to:

Department of Veterans Affairs Wilkes-Barre VA Medical Center

ATTN: Scot Plank/ 36C24420R0075 1111 East End Blvd Wilkes-Barre, PA 18711

Email address: scot.plank@va.gov

Please return the completed form ASAP, but no later than 11:00 AM local time, March 24, 2022.

If you have any questions, please contact the Contracting Officer: scot.plank@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.

The Contractor … 0 1 2 3 4 5

QUALITY – MANAGEMENT & WORKMANSHIP

1.

Provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract 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.

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

COMPLIANCE & SAFETY

14.

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

15.

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.

16.

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

INFECTION CONTROL

17.

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

OVERALL CUSTOMER SATISFACTION

18. Demonstrated reasonableness in modifications cost proposal.

19.

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

YES NO

20.

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