36C24918R0366-0001001.pdf

ATTACHMENT 2: PAST PERFORMANCE QUESTIONNAIRE

PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for Project 603-17-801, Site Preparation for Steris

Harmony EMS OR Anesthesia Supply Booms-Robley Rex VA Medical Center in Louisville, Kentucky.

PAST PERFORMANCE INSTRUCTIONS

The NCO 9 Network Contracting Activity has issued a solicitation to Site Preparation for Steris

Harmony EMS OR Anesthesia Supply Booms at the Robley Rex VA Medical Center, Project 603-17-

801.

Past performance information will be used to evaluate proposals received. Section A is to be completed by the Offeror. Section A of the enclosed questionnaire lists the contractor who has identified your office as a source to evaluate their past performance. Section A also authorizes release of this information to

NCO 9 Network Contracting Activity.

The Offeror must provide this entire document to each of its assessors. The Assessor shall only submit past performance questionnaires directly to the Contract Specialist-Roxie Ann Keese by way of email at roxie.keese@va.gov.

Section B in its entirety is to be completed by the assessor(s). An individual assessor knowledgeable of the contractor’s quality of supplies and services rendered is requested to verify, complete the questionnaire, and submit to the Contracting Office. If evaluating more than one contract for the same contractor, use a separate questionnaire for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing your assessment is greatly appreciated. The questionnaire should be completed as soon as possible but not later than July 6, 2018 2:00pm Eastern Time. Assessor is requested to send electronically to (Roxie.

Keese@va.gov). Assessor: Please so not sent this information to the Offeror being evaluated.

Thank you in advance for your cooperation and expeditious response to this request.

PAST PERFORMANCE QUESTIONNAIRE

SECTION A: Contractor Information (to be completed by the contractor for who past performance information is being collected, prior to forwarding to assessors)

Solicitation Number 36C24918R0366

Project/Requirement 603-17-801 |Site Preparation for Steris Harmony EMS OR Anesthesia Supply

Booms

Customer/Agency Department of the Veteran Affairs, NCO 9, Louisville, KY 40206

1. Prospective Government Contractor’s______________________________________

Name and Address: ______________________________________

2. Contractor Point of Contact: ___________________________________________

3. Phone number (with area code): ___________________________________________

4. Assessor Contract Award number: _________________________________________

5. Description of Services provided under contract:

6. Contract award date: ___________ Contract Amount: Initial ___________Final ____

7. Period of Performance or Delivery Date: _________________________

ASSESSOR INFORMATION:

Assessor Name

Title

Phone Number/Email Address

8. Authorization is hereby granted to provide the information requested in this questionnaire to NCO 9

Network Contracting Activity, Murfreesboro, Tennessee

(Signature)

(Name and Title of Authorizing Official) (Date)

SECTION B: Assessors Information (to be completed by assessors.

RATING SCALE Definitions

Past Performance Evaluation Ratings

Rating Description

ACCEPTABLE Based on the offeror’s performance record, the

Government has a reasonable expectation that the offeror will successfully perform the required effort, or the offeror’s performance record is unknown. (See note below.)

UNACCEPTABLE Based on the offeror’s performance record, the

Government has no reasonable expectation that the offeror will be able to successfully perform the required effort.

The questions on the survey (see below) shall be rated in accordance with the definitions provided in the

Rating Scale. Any unsatisfactory or marginal rating shall be supplemented with an explanation in the space provided.

QUALITY OF SERVICE

1. Rate the contractor’s compliance with contractual requirements.

ACCEPTABLE _____ UNACCEPTABLE____

2. Overall rating of contractor quality of service.

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING: ____________________________

SCHEDULE

1. Delivery of service was within required time period specified by contract requirements.

2. Rate the contractor’s ability to control cost and submit invoices.

Are invoices complete, accurate, and timely?

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING: ____________________________

BUSINESS RELATIONS

1. Overall rating of contractor’s business practices (e.g. maintaining

A positive working relationship, business ethics, timely and effectively

Resolution of any problems, etc.)

2. Rate the working relationship between contractor’s management, and your company (i.e. contractor’s history of reasonable and cooperative behavior, commitment of customer satisfaction; concern for the interest of the customer).

3. Rate the contractor's ability to submit required reports and/or invoices in a timely manner.

4. Rate the contractor’s responsiveness to customer complaint resolution.

5. Overall rating of contractor’s business relations.

How would you feel about awarding another contract to this contractor?

______ Would not hesitate to award another contract to this contractor.

______ Would most likely award another contract to this contractor.

______ Would think twice about awarding another contract to this contractor, but would do so if no better alternative existed.

______ Do not wish to award another contract to this contractor.

______ Would not award another contract to this contractor.

Overall Rating of Contractor’s performance (quality, schedule, business relations,) on contract being assessed.

ACCEPTABLE UNACCEPTABLE

VII. General Comments:

ASSESSOR:

Identify your role in the contract award or administration and the period of your involvement.

✓ Role Period of Involvement

Contract Specialist/Contracting Officer

Technical Project Lead/Project Officer

OTHERS

(Signature) (Date)

(Typed or Printed Name) (Organization Name)

(Phone Number) (Organization)