S02 - Attachment 22 - Past Performance Questionaire (1).pdf

Procurement Sensitive Do Not Disclose --- See FAR Subparts 2.101 and 3.104-4 FOR

OFFICIAL USE ONLY

ATTACHMENT 2 - PAST PERFORMANCE QUESTIONNAIRE

PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for Project 614-CSI-108, DB Install Hi-Tech, High-Cost

Equipment for the Cardiac Catheterization Laboratory, Memphis VA Medical Center, Memphis, Tennessee 38104.

PAST PERFORMANCE INSTRUCTIONS

The NCO 9 Network Contracting Activity has issued a solicitation to Project 614-CSI-108, DB Install Hi-

Tech, High-Cost Equipment for the Cardiac Catheterization Laboratory.

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 June 30, 2022, at 12pm CT. 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

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 36C24922R0058

Project/Requirement Project 614-CSI-108

Customer/Agency Memphis VA Medical Center, 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:

6. Contract Award Date: _______________ Contract Amount: Initial ___________

Final___________

7. Period of Performance:

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

Rating Description

Exceptional Proposal meets requirements and indicates an exceptional approach and understanding of the requirements. Proposal has strengths and no weaknesses. Risk of unsuccessful performance is minimal.

Highly

Acceptable

Proposal meets requirements and indicates a thorough approach and understanding of the requirements. Proposal contains strengths which outweigh any weaknesses. Risk of unsuccessful performance is low.

Acceptable Proposal meets requirements and indicates an adequate approach and understanding of the requirements. Strengths and weaknesses are offsetting or will have little or no impact on contract performance. Risk of unsuccessful performance is moderate.

Marginal Proposal does not clearly meet requirements and has not demonstrated an adequate approach and understanding of the requirements. The proposal has one or more weaknesses which are not offset by strengths. Risk of unsuccessful performance is high.

Unacceptable Proposal does not meet requirements and contains one or more deficiencies. Proposal is un-awardable.

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.

EXCEPTIONAL__HIGHLY ACCEPTABLE__ACCEPTABLE__MARGINAL__UNACCEPTABLE__

2. Overall rating of contractor quality of service.

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

SCHEDULE

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

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

Are invoices complete, accurate, and timely?

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.)

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).

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

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

9. 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 contact 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.

EXCEPTIONAL HIGHLY ACCEPTABLE ACCEPTABLE MARGINAL 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)