PAST PERFORMANCE QUESTIONNAIRE - revised.docx

PAST PERFORMANCE QUESTIONNAIRE

PART 1 (TO BE COMPLETED BY THE OFFEROR)

Provide the following information requested in this format for each of the projects/contracts being described. Projects may be on going or have been completed within five (5) years prior to the solicitation issue date. Provide accurate information on the contracts you identify. The 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: 36C24823R0205 – Home Oxygen – Bay Pines, Florida

A. Contractor Name:

1. Point of Contact:

2. Title:

3. Email:

4. Phone:

B. Project/Contract Title:

C. Contract Specifics:

1. Contract Number:

2. Total Contract Value:

3. Period of Performance:

4. Description of Services provided:

Authorization is hereby granted to provide the information requested in this questionnaire to NCO 8, Bay Pines, Florida.

(Signature)

(Name & Title of Authorizing Official) (Date)

PART 2 (TO BE COMPLETED BY THE ASSESSOR)

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

This survey should be completed by an assessor with sufficient familiarity of the Offeror’s performance and returned by the assessor no later than the offer due date and time of the solicitation to melva.stennis@va.gov. Please reference “36C24823R0205 - Past Performance/Company Name” in the subject field of your email.

RATING SCALE Definitions

Not Applicable

No performance record identifiable within the area of evaluation.

The questions in the survey (see below) shall be rated in accordance with the definitions provided in the Rating Scale above. Any unsatisfactory or marginal rating shall be supplemented with an explanation in the space provided below.

1. QUALITY:

Adequacy/effectiveness of quality control program and adherence to contract quality assurance requirements (without adverse effect on performance).

E

G

S

M

U

N

2. SCHEDULE/TIMELINESS OF PERFORMANCE:

Compliance with contract delivery/completion schedules including any significant intermediate milestones.

G

S

M

U

N

3. CUSTOMER SATISFACTION:

Contractor was reasonable and cooperative in dealing with your staff (including the ability to successfully resolve disagreements/disputes; responsiveness to administrative reports, businesslike and communication).

G

S

M

U

4. MANAGEMENT/ PERSONNEL/LABOR

Ability to assimilate and incorporate changes in requirements and/or priority, including planning, execution and response to Government changes.

5. COST/FINANCIAL MANAGEMENT

G

S

M

U

Ability to meet the terms and conditions within the contractually agreed price(s).

Have there been any indications that the Contractor has had any financial problems?

If yes, please explain below.

6. SAFETY/SECURITY

Yes

No

Contractor’s ability to maintain an environment of safety, adhere to its approved safety plan, and respond to safety issues.

Contractor compliance with all security requirements.

G

S

M

U

N

Ability to successfully respond to emergency and/or surge situations (including notifying COR, PM or Contracting Officer in a timely manner regarding urgent contractual issues).

Compliance with contractual terms/provisions (explain if specific issues)

G

S

M

U

N

In summary, provide an overall rating for the work performed by this Contractor.

Yes

No

Please provide straightforward responses to the questions above (if applicable) and/or additional remarks. Furthermore, please provide a brief narrative addressing specific strengths, weaknesses, deficiencies, or other comments which may assist our office in evaluating performance risk (attach additional pages if necessary):

Signature of Assessor / Evaluator Date

Name:

Title:

Email: