Past Performance Questionnaire.pdf

Department of Veterans Affairs Network Contracting Office 4

1010 Delafield Road Pittsburgh, PA 15215

1 | P a g e

Past Performance Questionnaire for:

CONTRACTOR INFORMATION

Company Name Street Address

Point of Contact City Phone Number State Reference Project Title

Zip Code

Contract Period (start to finish): Email

Contract Number Contract Value

Description of Work

Role of Contractor on This Project 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. Once completed, please send the form to the Contracting Officer via postal mail or email directly to:

Department of Veterans Affairs

Please return the completed form ASAP, but no later than

If you have any questions, please contact the Contracting Officer:

INSTRUCTIONS TO OFFEROR

Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). Information should match one of your projects that you are submitting in the Experience section of your proposal. Complete up to five of these (one per project). 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.

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 UNACCEPT-

ABLE 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

The Contractor … 0 1 2 3 4 5

1.

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

REMARKS:

2.

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

REMARKS:

3.

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

REMARKS:

4.

5.

6.

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

REMARKS:

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

REMARKS:

Suggested alternative approaches to problems.

REMARKS:

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

REMARKS:

The Contractor … 0 1 2 3 4 5

7.

8.

Provided timely notices of possible delays/schedule revisions.

REMARKS:

9.

Developed realistic and met approved progress schedules.

REMARKS:

The Contractor … 1 0 2 3 4 5

10.

Displayed initiative to solve problems.

REMARKS:

11.

12.

13.

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

REMARKS:

TIMELINESS AND ADHERENCE TO SCHEDULE

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

REMARKS:

BUSINESS PRACTICES/CUSTOMER RELATIONSHIP AND ABILITY TO PERFORM

Performed well independently of owner/government guidance, oversight, and assistance?

COMPLIANCE & SAFETY

The Contractor … 0 1 2 3 4 5

14.

Submitted Reports (i.e., daily, test, logs) / records completely and accurately to satisfy your requirements.

REMARKS:

15.

Applicable to Federal Contracts –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.

REMARKS:

16.

Safety program complied with federal regulations. Contractor implemented and followed their safety plan and ran a “safe jobsite”.

REMARKS:

The Contractor …

17.

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

OVERALL CUSTOMER SATISFACTION

The Contractor … 0 1 2 3 4 5

18.

Demonstrated reasonableness in modifications cost proposal.

REMARKS:

19.

Was the contractor ever issued a cure or show cause notice under the referenced contract?

REMARKS:

NO

20.

Would you award another contract to this contractor?

REMARKS:

YES NO

OVERALL PERFORMANCE RATING

GENERAL REMARKS

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

The contractor’s overall performance was: 21.

YES

Amanda.Murphy5@va.gov