EXHIBIT C - Past Performance Questionnaire.docx
DOCX document 297 KB Posted
- Solicitation number
- 36C24426R0105
About this file
This is a Past Performance Questionnaire template used by the Department of Veterans Affairs Network Contracting Office 4 to evaluate contractor performance on past projects relevant to solicitation 503-26-104, Replace Underground Sprinkler and Domestic Water Mains at the Altoona VA Medical Center.
The questionnaire is completed in two sections: contractors provide their company information and project details, then submit the form to reference contacts who evaluate performance across multiple categories on a scale of 0 (Neutral) to 5 (Exceptional). Reference contacts assess six quality management and workmanship criteria, three timeliness and schedule adherence measures, four business practices and customer relationship factors, three compliance and safety items, one infection control requirement, and three overall customer satisfaction questions. Specific evaluation areas include contractor's provision of experienced management, ability to hire and retain qualified personnel, quality control plan implementation, timely deficiency correction, submittal clarity, schedule development and adherence, problem-solving initiative, subcontractor management, change order timeliness, report accuracy, compliance with federal laws and regulations, safety program compliance, infection control processes, reasonableness of modification costs, and likelihood of future contract awards. Reference contacts must submit completed questionnaires directly to the Contracting Officer (Christopher.Clements1@va.gov and Elijah.mcintosh@va.gov) by 11:00 am EST on May 12, 2026, with an overall performance rating and detailed remarks required.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C24426R0105_2 5.15.26.pdf | ||
| Water Safety Plan Specifications.pdf | ||
| 005 TP01 Fire Protection Outline.doc | DOC document | |
| 503-26-104 SOW.pdf | ||
| 503-26-104 - Architect-Engineer Qualification Eval Factors.pdf | ||
| P10 -503-26-104 - Architect-Engineer Qualification Eval Factors.pdf | ||
| P01 - 503-26-104 SOW.pdf | ||
| 36C24426R0105.docx | DOCX document |
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Text version
Department of Veterans Affairs
Network Contracting Office 4 1010 Delafield Road Pittsburgh, PA 15215
Past Performance Questionnaire for:
503-26-104 Replace Underground Sprinkler and Domestic Water Mains
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 according 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):
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 email directly to:
Christopher.Clements1@va.gov and Elijah.mcintosh@va.gov
Please return the completed form ASAP, but no later than 11:00 am EST, 12 May 2026.
If you have any questions, please contact the Contracting Officer: Elijah.mcintosh@va.gov
RESPONDENT INFORMATION [completed by Reference Contact]
Company Name
Street Address
POC Name
City
Phone Number
State
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. |
| |_| |
| |_| |
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| 2. |
| Demonstrated ability to hire, maintain, and replace, if necessary, qualified construction personnel during the contract period. |
| |_| |
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| 3. |
| Provided and followed approved quality control plan and/or inspection procedures to meet contract requirements. |
| |_| |
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| 4. |
| Corrected deficiencies in timely manner and pursuant to their quality control procedures. |
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| 5. |
| Submittals clearly identified the proposed item IAW the specifications and drawings. |
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| 6. |
| Suggested alternative approaches to problems. |
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TIMELINESS AND ADHERENCE TO SCHEDULE
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| 7. |
| Contractor provided timely notices of possible delays/schedule revisions. |
REMARKS:
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| 8. |
| Timeliness in submitting submittals and reports and responding to agency inquiries, RFP's, etc. |
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| 9. |
| Developed realistic and met approved progress schedules. |
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BUSINESS PRACTICES/CUSTOMER RELATIONSHIP AND ABILITY TO PERFORM
| 10. |
| Displayed initiative to solve problems. |
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| 11. |
| How well did the contractor work independent of Government guidance, oversight and assistance? |
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| 12. |
| Subcontractors / tradesmen were adequately managed and coordinated. Explain any subcontracting issues (positive or negative) that impacted the performance of your contract(s). |
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| 13. |
| For contract changes, contractor provided timely and realistic change order proposals. |
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COMPLIANCE & SAFETY
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| 14. |
| Reports (i.e., daily, test, logs) / records were submitted completely and accurately satisfy the requirement. |
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| 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. |
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| 16. |
| Contractor’s safety program was in compliance with federal regulations. Contractor implemented and followed their safety plan and ran a “safe jobsite”. |
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INFECTION CONTROL
| 17. |
| Contractor had an Infection Control Process in place and complied with agency Infection Control Requirements. |
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OVERALL CUSTOMER SATISFACTION
| 18. |
| Demonstrated reasonableness in modifications cost proposal. |
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| 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 |
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| NO |
| OVERALL PERFORMANCE RATING: |
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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
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