36C24720R0008-013.pdf

PAST PERFORMANCE QUESTIONNAIRE Final version 5/1/2020

PAST PERFORMANCE

(To be completed by References)

Request for Proposal Number: 36C24720R0008, closing date: June 5, 2020

Submit completed Cover Sheet and Survey via email to:

Department of Veterans Affairs, RHJ VA Medical Center

109 Bee Street

Charleston, SC 29401

Samuel Smith, Contract Specialist

Network Contracting Office (NCO) 7

Phone: 843-789-7504

Email: samuel.smith8@va.gov

*Do not return this form to the contractor being evaluated. It is desired that this form be submitted to the person identified above, no later than 5 days before RFP closing date.

1. Handwritten responses are acceptable. If a response is handwritten, please print legibly.

2. If more space is needed for narrative comments, use the back of the survey or attach additional pages.

3. Your time and effort in providing this vitally important information is greatly appreciated.

GENERAL INFORMATION

Please provide the following information:

Your Company Name: ______________________________________

Person Filling Out Survey Form: ______________________________________

Phone Number: ______________________________________

Fax Number: _______ __________________________

Email Address: _______________ ______________________

For each contract include the following:

Contract Number(s)/ Title: ________________________________

Role and scope performance: ___ _________________________________

General Description of Contract Services: _______________________________________

Date awarded and date completed: _______________________________________________ mailto:samuel.smith8@va.gov

Contract Dollar Value (as awarded or as modified): __________________________________

Discussion, issues encountered, and resolutions: ______________________________________

REMARKS: (Add on separate sheet.)

CONTRACTOR PERFORMANCE EVALUATION SURVEY RATING SHEET

RATING SCALE

Please use the following rating to answer the questions. If you are unable to rate any item because it was not a requirements, never an issue, or you have no knowledge of the item in question, then you should mark “N/A”.

EVALUATION CRITERIA

Rating Description

Substantial Confidence

Based on the offeror’s recent/relevant performance record, the Government has a high expectation that the offeror will successfully perform the required effort.

Satisfactory Confidence

Based on the offeror’s recent/relevant performance record, the Government has a reasonable expectation that the offeror will successfully perform the required effort.

Limited Confidence

Based on the offeror’s recent/relevant performance record, the Government has a low expectation that the offeror will successfully perform the required effort.

No Confidence Based on the offeror’s recent/relevant performance record, the Government has no expectation that the offeror will be able to successfully perform the required effort.

Unknown Confidence (Neutral)

No recent/relevant performance record is available, or the offeror’s performance record is so sparse that no meaningful confidence assessment rating can be reasonably assigned.

NOTE: For statements indicating “No Confidence” or “Substantial Confidence”, please provide and explanation in the Comments section of the survey.

CONTRACTOR PERFORMANCE EVALUATION SURVEY RATING SHEET

FOR CONTRACT: 36C24720R0008

Substantial

Confidence

Satisfactory

Confidence

Limited

Confidence

No

Confidence

Unknown

Confidence

(Neutral)

A. QUALITY OF PRODUCT OR SERVICE

(1) The Contractor provided a product or service that conformed to contract requirements, specifications and standards of good workmanship

(2) The Contractor submitted accurate reports.

(3) The Contractor utilized personnel who were appropriate to the effort performed.

B. COST CONTROL

(1) The Contractor performed the effort within the estimated cost/price.

(2) The Contractor submitted accurate invoices on a timely basis.

(3) The Contractor demonstrated cost efficiencies in performing the required effort.

(4) The actual costs/rates realized closely reflected the negotiated costs/rates.

C. SCHEDULE

(1) The tasks required under this effort were performed in a timely manner and in accordance with the period of performance of the contract.

(2) The Contractor was responsive to technical and/or contractual direction.

D. BUSINESS RELATIONSHIPS

(1) The Contractor demonstrated effective management over the effort performed.

(2) The Contractor maintained an open line of communication so that the Contracting

Officer’s Representative

(COR) and/or Technical Point of Contact (TPOC) were apprised of technical, cost and schedule issues.

(3) The Contractor presented information and correspondence in a clear, concise and businesslike manner

(4) The Contractor promptly notified the COR, TPOC and/or Contracting Officer in a timely manner regarding urgent issues.

(5) The Contractor cooperated with the Government in providing flexible, proactive and effective recommended solutions to critical program issues.

(6) The Contractor made timely award to, and demonstrated effective management of, its subcontractors.

(7) The Contractor demonstrated an effective small/small disadvantaged business subcontracting program.

E. CUSTOMER

SATISFACTION

(1) The products/services provided adequately met the needs of the program.

(2) The Contractor was able to perform with minimal or no direction from the COR or

TPOC.

(3) I am satisfied with the performance of the Contractor under this effort.

F. Key Personnel

(1) The labor turnover in key personnel labor categories was minimal and did not adversely affect Contractor performance

(2) The Contractor proposed qualified personnel to fulfill the requirements of the contract.

G. OTHER:

(1) Would you award this firm another contract? ( ) Yes ( ) No If you answered “no”, provide an explanation.

(2) Was the contract terminated for default? ( ) Yes ( ) No

COMMENTS: (Required for ALL Poor and Excellent Ratings)