36C24718R0050-011.pdf

PAST AND PRESENT PERFORMANCE QUESTIONNAIRE

When Filled In This Document Is Source Selection Sensitive

Information IAW FAR 3.104 Attachment 2

A. GENERAL INFORMATION: Please correct any information below known to be inaccurate:

Contractor’s Name: ___________________________

Project Title or Brief Description of Work: ___________________________________________*Completion Date: __________

Contract Number Provided by Offeror: Dollar Amount $___________________

*Note: If offeror holds or has held other contracts with your agency/organization in the last 5 years, please complete separate evaluation forms for those contracts as well.

B. AGENCY INFORMATION: Work to be performed renovate/construct Pharmacy in a hospital.

Offeror submitted as:

Prime Contractor Sub-Contractor Key Personnel Teaming/Joint Venture Architect/Engineer

C. RESPONDENT INFORMATION (Person who is completing information):

Name of Respondent: _____________________ Title: _______________________________

Address: ______________________________ Telephone Number: ____________________ ______________________________ Fax Number: _________________________ ______________________________ Email Address: _______________________

D. EMAIL COMPLETED SURVEY FORM TO: Thaddeus.willoughby@va.gov. PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 5 that most accurately describes the contractor’s performance or situation. If there was no performance in this project that can be rated use “Not Applicable

(N/A)”. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 1 OR 2.

1 2 N 3 4 5 N/A Unsatisfactory Marginal Neutral Satisfactory Very Good Exceptional Performance did not meet contractual requirements.

There were serious problems and the contractor’s corrective actions were ineffective

Performance did not meet most contractual requirements.

There were problems, some of a serious nature, for which corrective action was only marginally effective.

The record is inconclusive or without comment.

Performance met contract 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 met all contract requirements and exceeded many to the government’s benefit.

Problems, if any, were negligible and were resolved in a timely, highly effective manner

The contractor did not perform this effort.

mailto:Thaddeus.willoughby@va.gov

CONTRACTOR’S NAME:____________________________

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

1 2 N 3 4 5 N/A

2 Delegated authority to project managers and/or site supervisors commensurate with contract requirements. Project manager’s role was clear.

1 2 N 3 4 5 N/A

3 Identified risks/problems as they occurred and offered constructive and/or viable solution/alternatives.

1 2 N 3 4 5 N/A

4 Was responsive and reasonable to contract changes from the standpoint of timeliness, suggested solutions, and price.

1 2 N 3 4 5 N/A

5 Displayed a cooperative attitude with government personnel before and after award.

1 2 N 3 4 5 N/A

6 Quality Control procedures and execution were concernment to the project.

1 2 N 3 4 5 N/A

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

1 2 N 3 4 5 N/A

8 Followed approved quality control plan. YES NO N/A 9 Home office participated in solving significant local problems.

1 2 N 3 4 5 N/A

10 Were there any claims by subcontractors/suppliers for none payment. If yes, please explain outcome in “Remarks”.

YES NO N/A

11 Provided accurate and complete line item cost proposals (modification) including all aspects of work required for each task.

1 2 N 3 4 5 N/A

12 Developed, managed, and adhered to realistic schedules and met established project milestones.

1 2 N 3 4 5 N/A

13 Were any innovative approaches/technologies used on the project? Please provide example under “Remarks”.

YES NO

14 How well did the firm implement small business subcontracting plan? Applicable to Large Businesses Only

1 2 N 3 4 5 N/A

15 Ability to maintain a quality workforce and subcontractors through project completion.

1 2 N 3 4 5 N/A

16 How would you rate the firm’s safety record for the project? Include the number reportable incidents in “Remarks”.

1 2 N 3 4 5 N/A

17 Firm’s emphasis on delivering a quality product was apparent in day-to-day operations.

1 2 N 3 4 5 N/A

18 Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in "Remarks."

YES NO N/A

19 Would you award another contract to this contractor?

If not, explain in "Remarks."

YES NO N/A

OVERALL ASSESSMENT

20 Overall, on the scale of 1 – 5, how would you rate the contractor being surveyed 1 2 N 3 4 5 N/A

CONTRACTOR’S NAME:____________________________

Remarks: