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Attachment A
PAST PERFORMANCE QUESTIONAIRE
RFQ: 36C25618Q0186
INSTRUCTIONS TO CONTRACTOR
Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and submit it according to the instructions, below.
INSTRUCTIONS TO REFERENCE CONTACT
Complete the RESPONDENT INFORMATION section below.
The contractor named below is submitting an offer for a United States Department of Veterans Affairs contract requirement, and has sent this form to you, in your role as a past performance reference contact. Please complete this form in full (all areas shaded in light yellow, below). Once completed, please send the form to the Contracting Specialist via email at Valarie.labat@va.gov
Please return the completed form by December 15 , 2017 10:00am local CST.
GENERAL INFORMATION [completed by Contractor]
Contractor Company Name
Address
Contractor Point of Contact Name
Point of Contact Phone Number
Email
Reference Project Title
Contract Number
Contract Period of Performance (start to finish):
Contract Dollar Value
Description of Work
Role of Contractor on This Project (check appropriate box) ☐ Prime Contractor ☐ Sub-contractor ☐ Key Personnel
RESPONDENT INFORMATION [completed by Reference Contact]
Company Name
Address
POC Name
Phone Number
Fax Number
Email
PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 5 that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 1 OR 2 in the Remarks section, below (text box will expand to whatever extent is necessary).
| UNSATISFACTORY |
| MARGINAL |
| SATISFACTORY |
| VERY GOOD |
| EXCEPTIONAL |
| Performance did not meet most contractual requirements to the government’s detriment. There were serious problems and the contractor’s corrective actions were ineffective. |
| Performance did not meet some contractual requirements to the government’s detriment. There were problems, some of a serious nature, for which corrective action was only marginally effective. |
| Performance met contractual requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory. |
| Performance met all contract requirements and exceeded some to the government’s benefit. There were a few minor problems, which the contractor resolved in a timely, effective manner. |
| Performance met all contract requirements and exceeded many to the government’s benefit. Problems, if any, were negligible and were resolved in a timely, highly effective manner. |
| The Contractor … |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| n/a |
| 1. |
| Quality of Product or Service |
| Product/Service met or exceed requirements | | | | | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Product was reliable, maintainable, inspectable | | | | | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Provided accurate reports/data/documentation | | | | | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Corrected deficiencies in an effective manner | | | | | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Corrected deficiencies with minimal government intervention | | | | | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Provided resolution of warranty defects | | | | | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Corrected deficiencies in timely manner | | | | | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Met established schedules/milestones | | | | | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Provided timely resolution of warranty defects | | | | | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Provided timely reports/date/documentation | | | | | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Timely completion of privileging/credentialing packages | | | | | |
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Provided satifastory interaction with the government satisfactory |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Cooperated with Government personnel after award |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Provided timely and effective communication |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Was responsive to contract changes |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Identified problems as they occurred and provided timely resolution |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Suggested alternative approaches to problems |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Home office participated in solving significant local problems. |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements. | | | |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | | | |
| ☐ | | | |
| Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period. | | | |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | | | |
| ☐ | | | |
| Timely of awards to subcontractors and management of subcontractors, including subcontract costs | | | |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | | | |
| ☐ | | | |
| 5. |
| Utilization of Small Business (applicable to contracts with subcontracting plans) |
| Provided good faith effort to meet goals | | | |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | | | |
| ☐ | | | |
| Followed approved quality control plan. | | | |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | | | |
| ☐ | | | |
| Provided effective quality control and/or inspection procedures to meet contract requirements. | | | |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | | | |
| ☐ | | | |
| Met reporting requirements (i.e. fSRS, FAPIIS, Safety and Labor Regulations, Recovered material, Hazadeous Material Identification) | | | |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | | | |
| ☐ | | | |
| Followed approved safety plan | | | |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | | | |
| ☐ | | | |
| Provided accurate reports/data/documentation | | | |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | | | |
| ☐ | | | |
| 7. | | | |
| How would you rate the contractor's overall performance? | | | |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | | | |
| ☐ | | | |
| 8. |
| Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.” |
| ☐ |
YES
NO
| 9. |
| Would you award another contract to this contractor? If not, please explain in “remarks.” |
| ☐ |
YES
NO
| 10. |
| To the best of your knowledge, is the contractor rated in CPARS? |
| ☐ |
YES
NO
REMARKS (Please use as much space as is needed – the box will expand as you type).
Name of Person Completing Form Signature