36C25619Q0963-003.pdf

PAST PERFORMANCE QUESTIONNAIRE

REFERENCE INSTRUCTIONS: The Michael E. Debakey VA Medical Center is considering the Offeror listed below for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. The intent of this form is to evaluate the offeror’s services. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation prohibits the release of the names of individuals providing reference information about Offeror’s past performance. This survey should be completed by an evaluator with sufficient familiarity of the offeror’s performance and returned to the contracting office by the closing date of the solicitation by e-mail to shasta.britt@va.gov.

Include the solicitation number on the subject line of all e-mails.

Offeror’s Name: _____________________________ Offeror’s e-mail: __________________________________

Request for Quote: ______________________________________________________________________________

Name of Person Completing the Evaluation: ______________________

Telephone: _______ E-mail: _______________

Title: _______________________________________________________

Company/Organization: ________________

Please rate the offeror in each of the following areas. Note: there is room for comments where you deem remarks would be helpful to our evaluation.

• Not Applicable: N/A

• 1: Performance clearly below the contract performance standard or requirement

• 2: Performance occasionally does not meet minimum contract performance standard or requirement

• 3: Performance that meets the minimum contract performance standard or requirement

• 4: Performance that meets and occasionally exceeds the contract performance standard or requirement

• 5: Performance that almost always exceeds the contract performance standard or requirement

1. Overall quality/satisfaction N/A 1 2 3 4 5

Overall satisfaction with the Offeror’s performance. Would you (the reference) choose to work with this offeror again?

2. Delivery performance N/A 1 2 3 4 5

Delivery performance includes delivery consistency, on time performance, and flexibility in responding to emerging issues and implementing required solutions.

3. Satisfaction with the quality of service delivered N/A 1 2 3 4 5

Rate the effectiveness and applicability of the plans and strategies delivered and the actual implementation of those.

4. Satisfaction with problem resolution N/A 1 2 3 4 5

This includes the offeror’s ability to solve problems, the speed in which they handle problems, and their effective delivery of resolutions.

mailto:shasta.britt@va.gov.

5. Satisfaction with the quality of contractor personnel N/A 1 2 3 4 5

Rate the quality of the contractor’s staff in executing the project work scope.

6. Have you issued a cure notice, show cause notice, suspension of progress payments or other letters directing the correction of a performance problem in the past 3 years?

Yes No If Yes, please explain.

7. Have you terminated this contractor for default within the past 3 years, or are there any pending termination actions?

Yes No If Yes, please explain.

8. Based on the offeror’s overall performance, would you award them another contract?

Yes No If No, please explain.

9. Have you discussed any adverse past performance problems with the Offeror and given them an opportunity to comment?

Yes No Please explain.

10. Do you file past performance information in a database that the Contracting Officer may search?

11. If the contract had options, were those options exercised?

12. List the dates of the contract period of performance (when were services provided)?

Dates: _______________________________________________________

13. What was the dollar value of the contract performed by the offeror?

Dollar Value: __________________________________________________

14. Provide a brief description of the services provided by the offeror for this contract.

Please attach any past performance database reports or other material you deem appropriate to a full understanding of the

Offeror’s past performance by the evaluator.