S02-Attachment 5-Past Performance Questionnaire-626A4-21-101.pdf

PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for Project 626A4-21-101, Renovate and Expand Physical Medicine Rehabilitation Services (PMRS) at the Alvin C. York VA Medical Center in Murfreesboro, Tennessee.

PAST PERFORMANCE INSTRUCTIONS

The NCO 9 Network Contracting Activity has issued a solicitation for Project 626A4-21-101, Renovate and Expand PMRS at the Alvin C. York 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 the 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-Vance Rosebush by way of email at vance.rosebush@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 September 30, 2022 at 2:00 pm Eastern Time. Assessor is requested to send electronically to (vance.rosebush@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.

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 36C24922R0091 Project/Requirement 626A4-21-101 Renovate and Expand PMRS Customer/Agency Department of Veteran Affairs, NCO 9, Murfreesboro, TN 37129

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: Assessor’s 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.

NOTE: In the case of an offeror without a record of relevant past performance or for whom information on past performance is not available or so sparse that no meaningful past performance rating can be reasonably assigned, the offeror may not be evaluated favorably or unfavorably on past performance (SEE FAR 15.305(a)(2)(iv)). Therefore, the offeror shall be determined to have unknown past performance. In the context of ACCEPTABLE/UNACCEPTABLE, “unknown” shall be considered

“ACCEPTABLE”.

SURVEY QUESTIONS

The following survey questions 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 the required time specified by the 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 effective resolution of any problems, etc.)

ACCEPTABLE ___ UNACCEPTABLE ___

6. Rate the working relationship between the contractor’s management and your company (i.e.

contractor’s history of reasonable and cooperative behavior, commitment to 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

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)