36C25918Q0420-003.docx

VA259-18-Q-0420

PAST PERFORMANCE SURVEY

OFFEROR INSTRUCTIONS: A separate record must be completed for each Past Performance Information and Survey; Offeror must directly send to the evaluator, requesting they complete and return as indicated on the attached Past Performance Survey, by not later 25 July 2018, to concesa.hubbard@va.gov and david.medina2@va.gov. Further, Offeror must include a copy of each requested Past Performance Information page with proposal/quote submission.

Solicitation Number: VA259-18-Q-0420

Name and address of Offeror:

Contract Details (i.e. Contract #/ Delivery or Task Order #, Title, Location, etc.)

Contract No.:

Contractor Name:

Date:

Title:

Location:

Type of Facility:

Assessor Full Name:

Assessor Position held or function in relation to project:

Assessor’s Company/Organization Name, Address and Phone number:

Assessor’s email address:

Please complete and return to: concesa.hubbard@va.gov and david.medina2@va.gov

PAST PERFORMANCE SURVEY

Reference Instructions: The Department of Veterans Affairs is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. Your comments are considered Source Selection Sensitive. Survey should be completed by the evaluator and returned to concesa.hubbard@va.gov and david.medina2@va.gov not later than the above date.

Please evaluate the Past Performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, provide additional information in the appropriate block or in the remarks section of this form.

O = Outstanding = Performance greatly exceeded contract requirements

A = Above Average = Performance exceeded contract requirements

S = Satisfactory = Performance met 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

NOTE: Do not use a color marking pen to circle the response. Best to use a ball point pen (Black or Blue) to circle your response.

Describe exactly what type of janitorial services or similar service(s) were provided to your company/organization?

Period of Performance (Provide dates):

Remarks:

Remarks:

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Remarks: ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________

PAST PERFORMANCE SURVEY – REMARKS SECTION

Additional Remarks regarding janitorial services:

Signature: Date:

Print Name:

Please email directly to concesa.hubbard@va.gov and david.medina2@va.gov

DO NOT return survey to the company you are evaluating.

Source Selection Sensitive FAR 3.104

FOR OFFICIAL USE ONLY