D.7 Past Performance Questionnaire - Updated.docx
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- Attached to
- V225--Wilkes-Barre VAMC Non-Emergent ALS/BLS Ambulance and Wheelchair Van Transportation Services
- Solicitation number
- 36C24425Q0902
About this file
This document is a Past Performance Questionnaire for a VA contract opportunity for non-emergent ambulance and wheelchair van transportation services at the Wilkes-Barre VAMC. The solicitation (Number 36C24425Q0902) is issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 4, with a close date of 10 October 2025 at 11:00am.
The questionnaire is designed to comprehensively evaluate a contractor's performance across three key assessment elements: Quality of Services, Timeliness of Performance, and Business Relations. It uses an adjectival rating system ranging from Excellent to Unsatisfactory, with space for narrative explanations. The form requires detailed information about the contractor's performance, including personnel qualifications, equipment maintenance, compliance with contractual terms, responsiveness, problem-solving abilities, and overall effectiveness. The evaluator is asked to provide an overall rating and indicate whether they would award to the contractor again.
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Text version
PAST/PRESENT PERFORMANCE QUESTIONNAIRE
SOLICITATION NUMBER – 36C24425Q0902
Wilkes-Barre VAMC Wilkes-Barre, PA
PLEASE COMPLETE THE FOLLOWING IDENTIFYING INFORMATION AND PAST PERFORMANCE ASSESSMENT. PLEASE SEND THE COMPLETED FORM TO CYNTHIA LAEMMERHIRT, CYNTHIA.LAEMMERHIRT@VA.GOV. SOLICITATION CLOSE DATE IS 10 OCTOBER 2025 AT 11:00AM.:
I. CONTRACTOR IDENTIFICATION:
Contractor:
Contract Number:
Period of Performance:
Negotiated price or cost at award:
Current estimated contract dollar amount:
Describe service acquired:
II. EVALUATOR INFORMATION:
Name:
Organization:
Phone Number:
(i.e., Contracting Officer, Program Manager, Contract Specialist/Administrator, Contracting Officer's Technical Representative, other, etc.)
Time on Contract:
III. ASSESSMENT ELEMENTS: Narrative statements are vital. Please provide a narrative for each element below and then an adjectival rating under Paragraphs III.A2, III.B.2, III.C.2, and an overall Past/Present Performance adjectival rating under par. III.F based on the Adjectival Rating Descriptions below. Attach additional pages if there is insufficient space in the comment space.
PERFORMANCE ADJECTIVAL RATINGS: Choose the appropriate adjective that most accurately describes the contractor’s performance based on the descriptions below.
| EXCELLENT |
| GOOD |
| SATISFACTORY |
| MARGINAL |
| UNSATISFACTORY |
Performance meets contractual requirements with most exceeded to the Government’s benefit. The contractual performance of the element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were highly effective.
Performance meets contractual requirements with some exceeded to the Government’s benefit. The contractual performance of the element being assessed was accomplished with no more than some minor problems for which corrective actions taken by the contractor was effective.
Performance meets contractual requirements. The contractual performance of the element contains some minor problems for which corrective actions taken by the contractor were satisfactory.
Performance does not meet some contractual requirements. The contractual performance of the element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented.
Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.
A. QUALITY OF SERVICES
1. Narrative: Address the Contractor’s ability to provide qualified personnel (including experienced managers and/or supervisors), necessary equipment which is properly maintained, quality control for performance of your contract, and contractor’s compliance with contractual terms and conditions.
2. Rating for Quality of Services: (Please check one and provide a narrative explanation of a Marginal or Unsatisfactory rating):
|_| Excellent |_|Good |_|Satisfactory |_|Marginal |_|Unsatisfactory
| B. TIMELINESS OF PERFORMANCE: | ||
| 1. Narrative: Address the Contractor’s ability to meet the contract’s | specific response times and Contractor’s timeliness in providing any | administrative reports/documents required by your contract. |
2. Rating for Timeliness of Performance: (Please check one and provide a narrative explanation of a Marginal or Unsatisfactory rating):
| C. BUSINESS RELATIONS | ||
| 1. Narrative: Address Contractor’s willingness to improve and correct | noncompliance issues and concerns. Describe Contractor’s ability to correct problems and prevent or mitigate potential problems in a timely manner. Does Contractor display initiative and flexibility? Do Contractor personnel promote a strong working relationship with your agency/organization? Are Contractor personnel courteous and | responsive? Do Contractor personnel interface effectively with your staff? |
2. Rating for Business Relations: (Please check one and provide a narrative explanation of a Marginal or Unsatisfactory rating):
D. Identify the contractor’s overall strengths and weaknesses:
E. Given the choice, would you award to this contractor again?
YES |_| NO |_|
If no, please explain:
F. CONTRACTOR’S OVERALL PAST/PRESENT PERFORMANCE RATING: (Please check one and provide a narrative explanation of a Marginal or Unsatisfactory rating):
Additional Comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name/Signature Date
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