36C24718R0088-003.doc

36C24718R0088

ATTACHMENT D - PAST PERFORMANCE INFORMATION

OFFEROR INSTRUCTIONS: A separate record must be completed for each Past Performance Information and Survey; Offeror must directly send to the evaluator, requesting they complete and return to the Contracting Officer as indicated on the attached Past Performance Survey, no later than 12 Noon 22 March 2018. Further, Offeror must include a copy of each requested Past Performance Information page with proposal submission.

Name of Offeror being evaluated:

Address of Offeror:

Contract Details (i.e. Contract Number / Delivery or Task Order Number, Title, Location, etc.):

Name of Evaluator:

Position held or function in relation to project:

Company Name:

Address:

Contact Phone Number:

Facsimile Number:

Please complete and return to above no later than 12 Noon (EST.) 22 March 2018:

ATTACHMENT C

PAST PERFORMANCE SURVEY

REFERENCE INSTRUCTIONS: Charlie Norwood VA Medical Center, Augusta GA is considering the offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. The intent of this form is to evaluate Sharps Waste Container Exchange System. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation (15.506) prohibits the release of the names of individuals providing reference information about Offeror’s past performance. survey should be completed by evaluator and returned no later than the above date, or by Facsimile to: 706-826-1029.

Please evaluate the past performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, please provide additional information in the appropriate block or in the remarks section of this form.

“O” = Outstanding Performance greatly exceeded the contract requirements

“A” = Above Average = Performance exceeded the contract requirements

“S” = Satisfactory Performance met the contract requirements

“M” = Marginal Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory

“U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements

Q1. To what extent did the contractor comply with contract requirements?

O A S M U

Q2. If reports were required, were they accurate in meeting contract requirements?

O A S M U

Q3. To what extent did the contractor use appropriate personnel for contract requirements?

O A S M U

Q5. Quality control:

O A S M U

T1. To what extent was contractor able to meet the performance schedule:

O A S M U

T2. What extent was contractor flexible in responding to changing needs?

O A S M U

T3. To what extent was the contractor reliable?

O A S M U

T4. To what extent was the contractor responsive to technical directions?

O A S M U

T5. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, please explain.

Yes No

C1. Would you award another contract to the party being evaluated? If no, please explain:

Yes No

C2. Was the customer satisfied with the end product? If no, please explain:

Yes No

C3. To what extent did contractor notify you of problems or potential problems?

O A S M U

15. Additional Remarks: