S02 - Attachment 3 - Past Performance Questionnaire.pdf

PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for Project 614-18-115, Renovate Operating Rooms at the

Memphis VA Medical Center in Memphis, Tennessee.

PAST PERFORMANCE INSTRUCTIONS

The NCO 9 Network Contracting Activity has issued a solicitation to Renovate the Operating Rooms at the Memphis VA Medical Center.

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 Contracting Officer -Robert Pritchard by way of email at

Robert.pritchard2@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, Friday, August 26, 2022, at 2:00pm CST. Assessor is requested to send electronically to

(Robert.Pritchard2@va.gov). Assessor: Please do not send this information to the Offeror being evaluated.

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

mailto:Robert.pritchard2@va.gov

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 36C24922R0015

Project/Requirement Renovate Operation Rooms

Customer/Agency Department of Veterans Affairs, NCO 9, Memphis Tennessee

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.

ACCEPTABLE ___ UNACCEPTABLE ___

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

SCHEDULE

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

ACCEPTABLE ___ UNACCEPTABLE ___

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

Are invoices complete, accurate, and timely?

ACCEPTABLE ___ UNACCEPTABLE ___

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

BUSINESS RELATIONS

5. Overall rating of contractor’s business practices (e.g. maintaining A positive working relationship, business ethics, timely and effectively Resolution of any problems, etc.)

ACCEPTABLE ___ UNACCEPTABLE ___

6. 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).

ACCEPTABLE ___ UNACCEPTABLE ___

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

ACCEPTABLE ___ UNACCEPTABLE ___

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

ACCEPTABLE ___ UNACCEPTABLE ___

9. Overall rating of contractor’s business relations.

ACCEPTABLE ___ UNACCEPTABLE ___

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

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.

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

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

Other

(Signature) (Date)

(Typed or Printed Name) (Organization Name)

(Phone Number)