36C24919R0075-075.docx

FOR OFFICIAL USE ONLY

Source Selection Sensitive Information—See FAR 2.101 & 3.104 TVHS Multiple Award Task Order Contract (MATOC) 36C24919R0075

ATTACHMENT - A

PAST PERFORMANCE QUESTIONNAIRE

1. TRANSMITTAL LETTER SAMPLE

<Your Company Letterhead>

Date: ___________________ To:

We have listed your firm as a reference for the work we have performed for you as listed below. Our firm has submitted a proposal under a project advertised by Network Contracting Office 09 (NCO 09), located at 1639 Medical Center Parkway, STE 400, Murfreesboro, Tennessee, 37129.

In accordance with Federal Acquisition Regulations (FAR), they will evaluate our firm's past performance, and you our candid response to the attached questionnaire will assist the evaluation team in this process. We understand that you have a busy schedule and your participation in this evaluation is greatly appreciated. Please complete the enclosed questionnaire as thoroughly as possible.

Understand that while the responses to this questionnaire may be released to the offeror, FAR 15.306 (e)(4) prohibits the release of the names of the persons providing the responses. Complete confidentiality will be maintained. Only one response from each office is required.

Please send your completed questionnaire to the following address. Do not return them to our company.

Department of Veterans Affairs Network Contracting Office 09 (NCO 09) Attn: Douglas J. Crowley or via email to: douglas.crowley@va.gov 1639 Medical Center Parkway Murfreesboro, TN 37129

If you have questions regarding the attached questionnaire, or require assistance, please contact Mr. Matthew Whisman at (859) 281-341.

Thank you for your assistance.

Please be advised that “E-Mail” is the preferred method of receiving the requested information.

<Signature and Title of Principal>

2. GENERAL INFORMATION: (Contractor to be evaluated)

Name of Contractor:

Point of Contact: Title: E-mail:

Address of Record: Office Phone: Fax:

Contract#: Dollar Amount:

Dates of Performance:

Contractor Performed as: |_|Prime Contractor |_|Sub-Contractor

Project Title and Brief Description of Work:

*Note: If offeror holds or has held other contracts with your agency/organization in the last 3 years, please complete separate evaluation forms for those contracts as well.

3. RESPONDENT INFORMATION: (Government Official)

Name of Respondent: Title: E-mail:

Address of Record: Office Phone: Fax:

4. TRANSMITTAL INSTRUCTIONS: E-mail completed survey to Douglas Crowley, Network Contracting Office 09 (NCO 09) at douglas.crowley@va.gov

5. PERFORMANCE INFORMATION: Choose the appropriate adjectival rating that most accurately describes the contractor’s performance.

TO BE COMPLETED BY CLIENT

PLEASE CIRCLE THE ADJECTIVE RATING WHICH BEST REFLECTS

YOUR EVALUATION OF THE CONTRACTOR’S PERFORMANCE.

1. QUALITY:

2. SCHEDULE/TIMELINESS OF PERFORMANCE:

3. CUSTOMER SATISFACTION:

4. MANAGEMENT/ PERSONNEL/LABOR

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

5. COST/FINANCIAL MANAGEMENT

Have there been any indications that the contractor has had any financial problems? If yes, please explain below.

Yes

No

6. SAFETY/SECURITY

7. GENERAL

Would you hire or work with this firm again? (If no, please explain below)

Yes

No

Please provide frank 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):