36C24818Q0302-002.docx

PAST PERFORMANCE QUESTIONNAIRE

PART 1 (TO BE COMPLETED BY THE QUOTER)

Provide the following information requested in this format for each of the projects/contracts being described. Projects may be on going and cannot have been completed no later 2 years prior to the solicitation issue date. Provide frank, concise comments regarding YOUR PERFORMANCE on the contracts you identify. Form may be re-typed or copied into a new solicitation enclosure, however all questions must be answered and all information must be provided.

Respondent Information for Solicitation: 36C24818Q0302 -Air Exchange Pressure Test & Hoods Certifications.

A. Contractor Name: _______________________________

B. Project/Contract Title: _______________________________

C. Contract Specifics:

1. Contract Number: _____________________

2. Total Contract Value: _____________

3. Period of Performance: _____________

4. Hospital or Medical Setting Other _________________________

D. Contact Information of Reference:

1. Name:

2. Title:

3. Email:

4. Office Phone Number:

E. Brief Description of Work Performed:

1. Describe the specific elements of the work performed by your firm.

2. Address any technical areas about this project you consider uniquely relevant to this solicitation. Discuss size, scope, complexity and relative accomplishments (Explain unique circumstances and/or accomplishments and provide supporting information for verification).

FOR OFFICIAL USE ONLY

PART 2 (TO BE COMPLETED BY THE REFERENCE POC)

REFERENCE INSTRUCTION:

The intent of this form is to evaluate the quoter’s past performance. Information provided is considered sensitive, therefore, the release of individual’s names providing reference information about quoter’s past performance will not be disclosed and will remain with the contracting office.

This survey should be completed by an evaluator with sufficient familiarity of the quoter’s performance and returned by the evaluator no later than the offer due date (February 16, 2018) of the solicitation to rohan.mckenzie@va.gov. Please reference “36C24818Q0302-Past Performance/Company Name” in the subject field of your email.

Contractor’s Past Performance Evaluation

Contract Number:

Contractor:

Type of Service or Supply:

Rate each performance element by marking the box next to the appropriate number that best applies. Excellent = 4; Good = 3; Satisfactory = 2; Poor = 1; Unsatisfactory = 0 or Not Observed.

A. Quality of Service:

Excellent 4 |_| 3 |_| 2 |_| 1 |_| 0 |_| Unsatisfactory Not Observed |_|

Comments for quality and/or quantity of service:

B. Timeliness of Performance:

Excellent 4 |_| 3 |_| 2 |_| 1 |_| 0 |_| Unsatisfactory Not Observed |_|

Comments for timeliness of performance:

C. Business Relations (Resolving problems, complaints; response to inquiries, contractor personnel):

Excellent 4 |_| 3 |_| 2 |_| 1 |_| 0 |_| Unsatisfactory Not Observed |_|

Comments for business relations:

D. Financial Management:

Excellent 4 |_| 3 |_| 2 |_| 1 |_| 0 |_| Unsatisfactory Not Observed |_|

Comments for business relations:

E. Customer Satisfaction:

Is/was the contractor committed to customer satisfaction? |_| Yes |_| No

Based on the offeror’s overall performance, would you award them another contract? |_| Yes |_| No

Comments for customer satisfaction:

Signature of Reference POC/Evaluator Date

ATTACHMENT A

A. Quality of Service

B. Timeliness of Performance

C. Business Relations