36C25619R0152-055.docx

VA256-14-R-0731

PAST PERFORMANCE SURVEY

EXPANDING NLR PATIENT CARE BUILDING

To: ____________________ (Point of Contact)** ____________________ (Company)** ____________________ (Phone) ____________________ (Fax) ____________________ (E-Mail)** _____________________ (Name of Company requesting survey)**

The company from which you received this survey is competing for award of a contract with the Department of Veterans Affairs, Central Arkansas Healthcare System (CAVHS), North Little Rock Arkansas. As part of the CAVHS process for screening potential Offerors, this company is soliciting your input and assessment of its past performance for one or more projects they performed for your firm. Please respond to each of the questions below and forward the completed survey directly to the CAVHS Contract Specialist.

To consider your responses, the CAVHS Contract Specialist must receive your responses, either by fax or e-mail, not later than: 2:00PM CDT on September 15, 2014.

If you have any questions or comments, feel free to contact me. Thank you in advance for your assistance.

Jack S. Caperton Contract Specialist Phone: 501-257-1067 Fax: 501-228-8651 Email: Jack.Caperton@va.gov

Please identify the project(s) that this company has performed for your organization, description, city, state, and award amount and final dollar value at completion of contract:

Respond to the question using the following scale: O- Outstanding, A- Acceptable, S-Satisfactory, M- Marginal, U-Unacceptable.

1. Did the contractor commit adequate resources in timely fashion to the contract to meet the requirements and to successfully solve problems? O A S M U

2. To what extent did the contractor respond positively and promptly to technical direction, contract change orders, etc.?

O A S M U

3. How reliably did the contractor follow through on commitments?

O A S M U

5. How responsive do you think the contractor was to information requests, issues, or problems during the course of the contract? O A S M U

6. How effective has the contractor been in identifying requirements?

O A S M U

8. To what extent did the contractor issue professional correspondence?

O A S M U

9. How well did the contractor adhere to the Statement of Work? O A S M U

12. To what extent did the contractor submit required reports and documentation in a timely manner? O A S M U

17. To what extent was the contractor effective in interfacing with the Government staff? O A S M U

18. What was your level of overall customer satisfaction? O A S M U

Respond: Yes or No.

20. Were there any cure notices issued? Yes: ____ No: ____

21. Was contractor pro-active? Yes: ____ No: ____

22. Did contractor suggest cost-saving changes? Yes: ____ No: ____

23. Would you recommend this contractor? Yes: ____ No: ____

For Federal contracts:

24. Were there any Labor Department Investigations? Yes: ____ No: ____

24a. If yes, please describe reason and final outcome.

25. Were there any safety investigations? Yes: ____ No: ____

25a. If yes, please describe reason and final outcome.

26. Were there any security investigations? Yes: ____ No: ____

26a. If yes, please describe reason and final outcome.

27. Was there a partial or complete termination for default or convenience?

Yes: ____ No: ____

27a. If yes, please describe reason and final outcome.

28. Are there any pending terminations? Yes: ____ No: ____

29. What is/was the duration of the contract? _____________________

30. Were there any performance issues regarding the contractor’s work? If yes, please describe (use a separate sheet of paper if necessary).

Please provide other comments (Use a separate sheet of paper if necessary):

Signature: ____________________________

Date: ____________________________

**Required