36C24520R0082-004.pdf

Synopsis Attachment 4 Project Name: Renovate and Expand for Clinical Services Project Number: 581-306

PAST/PRESENT PERFORMANCE QUESTIONNAIRE (PPQ)

WHEN FILLED IN THIS DOCUMENT IS SOURCE SELECTION SENSITIVE INFORMATION IAW FAR 2.101 & 3.104

SECTION 1: CONTRACT IDENTIFICATION

A. Contractor: __________________________________________

B. Contract number: ______________________________________

C. Contract type: ______________________________

D. Was this a competitive contract? Yes _____ No _____

E. Period of performance:

F. Initial contract cost: $____________________________

G. Current/final contract cost: $_______________________________

H. Reasons for differences between initial contract cost and final contract costs:

I. Description of service provided:

SECTION 2: CUSTOMER OR AGENCY IDENTIFICATION

A. Customer or agency name: ____________________________________________________

B. Customer or agency description (if applicable): ___________________________________

C. Geographic description of services under this contract, i.e. local, nationwide, worldwide, other commands:

SECTION 3: EVALUATOR

IDENTIFICATION

A. Evaluator's name: ____________________________________________________________

B. Evaluator's title: _____________________________________________________________

C. Evaluator's phone/fax number: _________________________________________________

D. Length of time (number of years/months) evaluator worked on subject contract: __________

Name of Firm Evaluated

Name of person completing evaluation

Job title of person completing evaluation

Evaluator’s contact info – phone & e-mail

Evaluator’s Company (or Gov’t Entity) Name

Evaluator’s Company (or Gov’t Entity)

City & State

Type of work Performed by Evaluated Firm

(i.e.: investigation, design, construction inspection, etc.)

Brief description of the project: ___________________________________________________

Initial contract fee

Final amount paid

Year work began

Year work was completed

Was the work completed on time? __________ If not, why not? ________________________

Was the initial fee reasonable?

Was the final fee, including all modifications, reasonable?

Was the work as thorough and detailed as expected or desired?

For the following questions, use this rating scale: Violet = Outstanding, Blue = Good, Green =

Acceptable, Yellow = Marginal, Red = Unacceptable and N/A = Not applicable

Violet Blue Green Yellow Red N/A

How was the quality of any draft or intermediate submittals?

How was the quality of the final submittal?

How well did this firm examine alternatives, if applicable (Examined all reasonable alternatives? Evaluations of alternatives well reasoned?)

Were cost estimates prepared by this firm detailed and accurate?

If this firm produced a design, was the cost of the construction project kept within budget?

If questions arose regarding the firm’s work or if errors or omissions were found, after payment of the final invoice, how willing was the firm to answer those questions or correct those errors?

Was this firm cooperative and responsive to your needs and goals?

Did you feel the employees were highly qualified and knowledgeable?

SECTION 5: NARRATIVE SUMMARY

Would you have any reservations about soliciting this contractor in the future or having them perform one of your critical and demanding programs?

Please provide any additional comments concerning this contractor’s performance, as desired.

Evaluator’s Signature Date

SUBCONTRACTOR CONSENT:

We are currently participating as (CIRCLE ONE ANSWER): member of a joint venture, subcontractor, teaming partner, or key person with the prime contractor identified above in response to the referenced Request for Proposal. We understand that the Government is placing increased emphasis on past performance in order to obtain best value in source selections. In order to facilitate the performance confidence assessment process, we are signing this consent form to allow you to discuss or performance information with the prime contractor during the source selection process.

________________________ (Signature) ________________________ (Name and

Title)

(Signature and Title of individual who has the authority to sign for and legally bind the company)

Thank you for your prompt response and assistance!

Please return this completed questionnaire to: Ms. Alison Klein Mailing Address: Louis A Johnson VAMC Attn: 90C 1 Med Center Dr., Clarksburg, WV 26301

E-Mail: alison.klein@va.gov

Fax:304-623-7637