ATTACHMENT 1Survey - past perfromance.docx

ATTACHMENT 1: PAST PERFORMANCE QUESTIONNAIRE PAST PERFORMANCE/EXPERIENCE INFORMATION SURVEY OFFEROR INSTRUCTIONS: A separate record must be completed for each Past Performance/ Information and Survey for FAR 52.212-2; Offeror must directly send a copy of the survey to their selected evaluator for completion and the offeror is responsible for obtaining and submitting the completed survey with their submitted quote on or before the due date. Survey should be emailed directly to the Contracting Officer (and not to the company being evaluated) at darius.crane@va.gov Please put “Past Performance Survey for (Company Name) for 36C24722R0126_1 Medical Courier Service” in the subject line of your email.

Name of Offeror being Evaluated:

Address of Offeror:

Solicitation Number: 36C247220126_1 Medical Courier Services at the RHJVAMC

Name of Evaluator:

Position held or function in relation to project:

Company Name:

Address:

Contact Phone Number:

Email Address:

EVALUATOR INSTRUCTIONS:

The evaluator must identify the type of service, dates, location of service, and award value that are being utilized by the evaluator for this past performance survey. This information is needed to determine if the offeror has recent and relevant past performance providing courier services.

Type and date(s) of service being evaluated:

Location of service, and award value:

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

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

contract requirements

No

No

Additional Remarks:

Evaluator Printed Name/Signature

Date