36C25019R0010-003.pdf

PAST PERFORMANCE QUESTIONNAIRE

CONTRACT IDENTIFICATION

Healthcare for Homeless Veterans (Cleveland, OH) – Single

Men Solicitation: 36C25019R0010 The Contractor Must Fill Out This Section

(Customer must complete concur or does not concur) Part I

a. Contractor:

b. Contract number:

c. Contract type:

e. Was this a competitive contract? Yes ___________ No ________

f. Period of performance:

g. Initial contract price: $____________________________

h. Current/final contract price: $____________________________

i. Crew Size:

j. List all types of equipment used for service provided:

k. Description of service provided: (Please include any unusual requirements.)

The Customer Must Fill Out Remaining Sections Customer CONCURS / DOES NOT CONCUR with contractor’s statements above.

Part II

CUSTOMER OR AGENCY IDENTIFICATION

a. Customer or agency name:

b. Customer or agency description (if applicable):

c. Geographic description of services under this contract, i.e., local, nationwide, worldwide, other commands:

EVALUATOR IDENTIFICATION

a. Evaluator’s name:

b. Evaluator’s title:

c. Evaluator’s phone/fax number:

d. Number of year’s evaluator worked with Contractor:

Part III

EVALUATION

Please indicate your level of confidence based on your past experience with the contractor that they can satisfactorily perform the following elements by circling the appropriate letter using the scale provided.

This scale is defined as follows:

PERFORMANCE CONFIDENCE ASSESSMENT

High Confidence (H) Based on the offeror’s performance record, essentially no doubt exists that the offeror will successfully perform the required effort.

Significant Confidence (S) Based on the offeror’s performance record, little doubt exists that the offeror will successfully perform the required effort.

Confidence (C) Based on the offeror’s performance record, some doubt exists that the offeror will successfully perform the required effort

Unknown Confidence (U) No performance record is identifiable

“IAW FAR 15.305(a)(2)(iii) & (iv)

Little Confidence (L) Based on the offeror’s performance record, substantial doubt exists that the offeror will successfully perform the required effort. Changes to the offeror’s existing process may be necessary in order to achieve contract requirements.

No Confidence (N) Based on the offeror’s performance record, extreme doubt exists that the offeror will successfully perform the required effort.

PERFORMANCE

P1. Contractor’s ability to respond to questions in a timely manner H S C U L N

P2. Contractor’s ability to fulfill contract requirements so there are no unexpected maintenance activity or latent defects: H S C U L N

P3. Contractor’s ability to complete contract requirements: H S C U L N

P4. Contractor’s ability to provide adequate Staffing levels for the project size and Complexity: H S C U L N

P5. Contractor’s ability to communicate schedule and problem issues adequately and consistently H S C U L N

P6. Contractor’s ability for problem solving H S C U L N

P7. Contractor’s timeliness and accuracy of

Billing: H S C U L N

Provide any explanation you may feel is required to clarify any of the above responses. Provide additional sheets as required: _____________________________________________________

QUALITY

Q1. Contractor’s ability to provide an effective quality control program to ensure contract compliance: H S C U L N

Q2. Contractor ability to identify and correct weaknesses in management relative to contractor, personnel (quantity and/or quality), planning/scheduling, and quality of service H S C U L N

Q3. Contractor’s ability to correct discrepancies in contract performance. H S C U L N additional sheets as required: ______________

SCHEDULE

S1. Contractor’s ability to resolve contract problems Timely and effectively without extensive customer guidance: H S C U L N

S2. Contractor’s ability to successfully respond to emergency and/or surge situations without extensive customer guidance, to include:

Special Event/Visit H S C U L N

Weather Delays H S C U L N Gov’t Caused Delays H S C U L N additional sheets as required: ____________________________________________________

MANAGEMENT

M1. Contractor’s ability to provide experienced/qualified management personnel to meet contract requirements. H S C U L N

M2. Contractor’s ability to resolve customer complaints timely. H S C U L N

Part IV

Government contracts only: Has/was this contract partially or completely terminated for default or convenience or are there any pending terminations?

Yes ____ Default ____ Convenience _____ Pending Terminations ____ NO ____ If yes, explain (e.g., inability to meet price, performance, or delivery schedules, etc.)

Narrative Summary

a. What were the contractor’s greatest strengths in the performance of the contract?

b. What were the contractor’s greatest weaknesses in the performance of the contract?

c. Were there any environmental compliance difficulties experienced during performance of this contract?

d. Would you have any reservations about soliciting this contractor in the future or having them perform one of your critical and demanding projects?

e. Are there any other issues not covered you feel important to note about performance of this contractor?

Part V

Considering all the information provided above, please rate your overall opinion on the contractor’s ability to accomplish requirement.

(High Confidence) (Significant Confidence) (Confidence) (Unknown Confidence) (Low Confidence) (No Confidence)

Evaluator’s Signature Date

Thank you for your prompt response and assistance!

Contracting Officer: Davina Perry; Davina.Perry@va.gov Phone: 216-447-8300 Ext. 3816 Fax: 216-447-8310