36C25020Q0505-019.pdf

ATTACHMENT D.4 PAST PERFORMANCE SURVEY

Reference RFQ: 36C25020Q0505

INSTRUCTIONS: The Network Contracting Office (NCO) 10 is considering the Company (Quoter) listed below for award of a Department of Veterans Affairs Contract. You have been identified as a previous/current purchaser of the Company’s services, and your assistance with establishing the performance history for the Company is requested. Please note that your comments are considered source selection information, and will not be shared in any way with the Company or any party outside the Department of Veterans Affairs. This survey should be completed by an evaluator with sufficient knowledge of the Company’s performance.

This survey must be received by the Contracting Officer via email at Karen.Williams4@va.gov no later than the closing date and time of the solicitation. The Company should provide this information to you.

Information of the Company (Quoter) being evaluated:

Company Name: ___________________________________________________

Company Address: __________________________________________________

Information of the Evaluator:

Evaluator Name and Title: _______________________________________

Company Name: ______ ___________________________________________

Phone Number: _______________________________________

Address: _______________________________________

Information on contract;/service assessed for purpose of this evaluation

Contract Type and Dollar Value: __________________________________________________________________

Brief Description of Work: ________________________________________________________________________ mailto:Karen.Williams4@va.gov

***Please provide supporting comments for each question below; explaining the reason a particular rating was given.***

“O” =Outstanding = Performance greatly exceeded the contract requirements “A” =Above Average = Performance exceeded the contract requirements “S” = Satisfactory = Performance met the contract requirements “M” = Marginal = Performance met the minimum contract requirements, but some material aspects of the contractor’s performance were less than satisfactory “U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements Please rate and provide information and detailed comments for the following: Circle one

1. To what extent did the contractor comply with contract requirements? O A S M U

2. If reports were required, were they accurate in meeting contract requirements? O A S M U

3. To what extent did the contractor use appropriate personnel for contract requirements? O A S M U

4. To what extent did the contractor display technical expertise? O A S M U

5. To what extent was contractor able to meet the performance schedule? O A S M U

6. To what extent was contractor flexible in responding to changing needs? O A S M U

7. To what extent was the contractor reliable? O A S M U

8. To what extent was the contractor responsive to technical directions? O A S M U

9. To what extent did contractor notify you of problems or potential problems? O A S M U

10. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, please explain.

Yes No

11. Would you award another contract to the party being evaluated? If no, please explain:

12. Was the customer satisfied with the end product? If no, please explain:

Additional Comments:

Signature of Evaluator:_____________________________________________

Date:____________