36C24519Q0587-004.doc

PAST PERFORMANCE QUESTIONNAIRE INSTRUCTIONS

Department of Veterans Affairs The information obtained from this questionnaire will be utilized to evaluate the past and present performance of offerors submitting quotes in response to solicitation 36C24519Q0587. The information you provide will be instrumental in allowing the Government to evaluate how well the contractor performed under your contract(s).

a.

Please complete all sections of the attached questionnaire. Include your name and title, organizational address, e-mail address, telephone and fax number.

b.

Include the contractor’s name and address, the title and/or description of the type of work performed, the award number, the value of the contract (including options), the award and completion date of the project and the type of award/solicitation.

c.

Use the rating scale found on the bottom left corner of the questionnaire to rate each performance element.

d.

Comments are encouraged and would be appreciated. The last page may be used if additional space is needed for comments. Clear handwritten responses are sufficient.

e.

Please e-mail your response to the Contract Specialist whose number and address is shown at the bottom right corner of the questionnaire no later than 09/20/2019.

Thank you for your time and participation.

FOR OFFICIAL USE ONLY - SOURCE SELECTION SENSITIVE WHEN COMPLETED

PAST PERFORMANCE QUESTIONNAIRE

Your Name & Title yOUR Organizational Address

TEL NO.

FAX :

E-MAIL:

CONTRACTOR’S NAME & ADDRESS

TITLE OR DESCRIPTION OF REQUIREMENT:

CONTRACT NUMBER:

CONTRACT VALUE (INCLUDING OPTIONS):

CONTRACT TYPE:

FORMCHECKBOX

FIXED PRICE

FORMCHECKBOX

COST + FEE

FORMCHECKBOX

COMPETITIVE

FORMCHECKBOX

NON-COMPETITIVE

FORMCHECKBOX

SET-ASIDE

FORMCHECKBOX

SEALED BID

FORMCHECKBOX

NEGOTIATED

FORMCHECKBOX

SEALED BID

FORMCHECKBOX

NEGOTIATED

CONTRACT AWARD & COMPLETION DATE:

1.

Contractor demonstrated a thorough understanding of technical requirements of the contract/task.

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Comments:

2.

Contractor anticipated/identified and resolved problems effectively.

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Comments:

3.

Contractor managed and directed resources (i.e. personnel, subcontractors, equipment, etc.) effectively.

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Comments:

4.

Contractor provided the necessary skilled personnel to perform the required work.

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Comments:

5.

Contractor retained the necessary skilled personnel and maintained a low turnover rate.

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Comments:

FOR OFFICIAL USE ONLY - SOURCE SELECTION SENSITIVE WHEN COMPLETED

PAST PERFORMANCE QUESTIONNAIRE

6.

Contractor met scheduled contract delivery dates.

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Comments:

7.

Contractor provided accurate, complete and high quality deliverables.

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Comments:

8.

Contractor complied with the terms of the contract.

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Comments:

9.

Contractor was diligent in forecasting and controlling contract cost.

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Comments:

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

FORMCHECKBOX

Comments:

Phillip G Duba Phillip.Duba@va.gov

304.263.0811 X2043

NA

No Knowledge of This Element

FOR OFFICIAL USE ONLY - SOURCE SELECTION SENSITIVE WHEN COMPLETED