D.2 - Past Performance Survey.docx
DOCX document 23 KB Posted
- Attached to
- North Texas Hospital Patient Porters
- Solicitation number
- 36C25726Q0551
About this file
This is a Past Performance Survey form used by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 17 to evaluate contractor performance on solicitation 36C25726Q0551 for North Texas Hospital Patient Porters. The survey must be completed by the Contracting Officer's Representative (COR) or Point of Contact (POC) and returned to Romya Turner (Romya.turner@va.gov) or Shannon Hodgson (Shannon.hodgson@va.gov) no later than 10:00 AM Central Time on June 15, 2026.
The form evaluates contractor performance across nine key criteria using a six-point rating scale: personnel qualifications and experience, ability to hire and maintain qualified staff with adequate coverage, schedule adherence, cooperation with government personnel, timely resolution of discrepancies, work quality meeting or exceeding acceptable levels, alternative problem-solving approaches, initiative in problem-solving, and overall recommendation for future contract award. The rating scale ranges from 1 (Unsatisfactory) to 6 (Exceptional), with 3 indicating no past performance record or inconclusive information. Respondents must provide justification comments for any rating outside of Satisfactory (4), with additional space available for extended remarks. The form collects comprehensive contractor information including name, address, contract number, dollar value, and contact details for both the COR/POC and Contracting Officer.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25726Q0551 0001_.pdf | ||
| RFQ 36C25726Q0551 .docx | DOCX document | |
| D.1 WD 2015-5253 rev 29.pdf | ||
| D.3 PAST PERFORMANCE REFERENCES.rtf | RTF text file |
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Text version
PAST PERFORMANCE SURVEY
36C25726Q0551
Return surveys to Romya Turner at Romya.turner@va.gov or Shannon Hodgson at Shannon.hodgson@va.gov no later than 10:00AM Central Time June 15, 2026.
A. GENERAL INFORMATION:
Contractor's Name:
Contractor’s Address:
Contract #:
Contract Dollar Value:
Contracting Officer’s Representative/Point of Contact (COR/POC):
COR/POC Ph #:
Contracting Officer:
Contracting Officer’s Ph #:
B. SERVICES PERFORMED:
C. PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 6 that most accurately describes the contractor's performance or situation.
1 - Unsatisfactory. Performance did not meet most contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective.
2 - Marginal. Performance did not meet some contractual requirements. There were problems and the contractor’s corrective actions were ineffective.
3 - None. No record of past performance or the record is inconclusive.
4 - Satisfactory. Performance met contract requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory.
5 - Very Good. Performance met all contract requirements and exceeded some to the government’s benefit. There were few minor problems which the contractor resolved in a timely, effective manner.
6 - Exceptional. 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 efficient manner.
E. DIRECTIONS
Please provide justification comments for all items for which any rating was given outside of Satisfactory. Space for your comments is provided in each area. If more space is needed, attach additional sheets to the end of the questionnaire and reference the respective question.
TO BE COMPLETED BY THE DELEGATED COR or POC
The contractor:
1. Provided experienced/qualified personnel to perform services.
1 2 3 4 5 6 N/A
Remarks______________________________________________________________________
2. Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period. Also provide coverage with qualified personnel during periods of leave or absence .
1 2 3 4 5 6 N/A
Remarks_____________________________________________________________________
3. Met established schedules.
1 2 3 4 5 6 N/A
Remarks______________________________________________________________________
4. Cooperated with Government personnel after award.
1 2 3 4 5 6 N/A
Remarks______________________________________________________________________
5. Provided timely resolution of contract discrepancies
1 2 3 4 5 6 N/A Remarks_____________________________________________________________________
6. Performed work that met or exceeded acceptable levels.
1 2 3 4 5 6 N/A
Remarks_____________________________________________________________________
7. Suggested alternative approaches to problems.
1 2 3 4 5 6 N/A
Remarks______________________________________________________________________
8. Displayed initiative to solve problems.
1 2 3 4 5 6 N/A
Remarks______________________________________________________________________
9. Would you recommend award of another contract to this contractor? Yes No
Remarks_____________________________________________________________________
| _________________________________ | ____________ | |
| Signature of COR/POC | date |
Past Performance Form version 1.1 p. 1 of 1
File details come from the government source that posted it. Updated .