Attch13_Past Performance Questionnaire.docx

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Attached to
Y1DA--Emergency Department and Support Expansion / 660-800
Solicitation number
36C25920R0096
Issued by

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This document contains a past performance questionnaire to be completed for a federal contract opportunity involving the construction of an emergency department expansion and support facilities at the Salt Lake City VA Medical Center.

The past performance questionnaire requests information about a contractor's performance on previous relevant projects, including quality, schedule, customer satisfaction, management, cost, safety, and general performance. It asks the client to provide ratings in these categories on a scale of exceptional, very good, satisfactory, marginal, and unsatisfactory. The federal contract opportunity involves providing all materials and labor to design and construct an 18,500 square foot emergency department addition and associated renovations with a budget between $10-20 million. The project is fully set aside for Service-Disabled Veteran-Owned Small Businesses and will be awarded by the Department of Veterans Affairs, Veterans Health Administration.

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PAST PERFORMANCE QUESTIONNAIRE

Solicitation Number:
Project Title:

CONTRACT INFORMATION (Contractor to complete Blocks 1-4)

1. Contractor Information
Firm Name:CAGE Code:
Address:DUNs Number:

Phone Number: Email Address:

Point of Contact: Contact Phone Number:

2. Work Performed as: |_| Prime Contractor |_| Sub Contractor |_| Joint Venture |_| Other Percent of project work performed:

If subcontractor, who was the prime (Name/Phone #):

3. Contract Information Contract Number: Delivery/Task Order Number (if applicable):

Contract Type: |_| Firm Fixed Price |_| Cost Reimbursement |_| Other (Please specify):

Contract Title: Contract Location:

Award Date (mm/dd/yy):

Contract Completion Date (mm/dd/yy):

Actual Completion Date (mm/dd/yy):

Explain Differences:

Original Contract Price (Award Amount):

Final Contract Price (to include all modifications, if applicable):

Explain Differences:

4. Project Description:

Complexity of Work |_| High |_| Med |_| Routine How is this project relevant to project of submission? (Please provide details such as similar equipment, requirements, conditions, etc.)

CLIENT INFORMATION (Client to complete Blocks 5-8)

5. Client Information Name: Title:

Phone Number: Email Address:

6. Describe the client’s role in the project:

7. Date Questionnaire was completed (mm/dd/yy):

8. Client’s Signature:

E
VG
S
M
U
N

Exceptional (Outstanding) Very Good (Above Average)

Satisfactory
Marginal
Unsatisfactory
Not Available

Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with few minor problems for which corrective actions taken by the Contractor were highly effective

Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with some minor problems for which corrective actions taken by the Contractor were effectiveSection D: Performance Information: Choose the letter on the scale that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY UNSATISFACTORY OR MARGINAL RATINGS.

Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the Contractor appear, or were, satisfactory.
Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being evaluated reflects a serious problem for which the Contractor has not yet identified corrective actions. The Contractor’s proposed actions appear only marginally effective, or were not fully implemented

Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains a serious problem(s) for which the Contractor’s corrective actions appear or were ineffective

No record of past performance or the record is inconclusive.

1. QUALITY:

a) Quality of technical data/report preparation efforts
E VG S M U N

a.1. Comments:

b) Ability to meet quality standards specified for technical performance
E VG S M U N

b.1. Comments:

c) Timeliness/effectiveness of contract problem resolution without extensive customer guidance
E VG S M U N

c.1. Comments:

d) Adequacy/effectiveness of quality control program and adherence to contract quality assurance requirements (without adverse effect on performance)
E VG S M U N

d.1. Comments:

2. SCHEDULE/TIMELINESS OF PERFORMANCE:

a) Compliance with contract delivery/completion schedules including any significant intermediate milestones. (If liquidated damages were assessed or the schedule was not met, please address below)
E VG S M U N

2.a.1 Comments:

b) Rate the contractor’s use of available resources to accomplish tasks identified in the contract
E VG S M U N

2.b.1. Comments:

3. CUSTOMER SATISFACTION:

a) To what extent were the end users satisfied with the project?
E VG S M U N

3. a.1. Comments:

b) Contractor was reasonable and cooperative in dealing with your staff (including the ability to successfully resolve disagreements/disputes; responsiveness to administrative reports, businesslike and communication)
E VG S M U N

3.b.1. Comments:

c) To what extent was the contractor cooperative, businesslike, and concerned with the interests of the customer?
E VG S M U N

3.c.1. Comments:

d) Overall customer satisfaction
E VG S M U N

3.d.1 Comments:

4. MANAGEMENT/ PERSONNEL/LABOR

a) Effectiveness of on-site management, including management of subcontractors, suppliers, materials, and/or labor force?
E VG S M U N

4.a.1. Comments:

b) Ability to hire, apply, and retain a qualified workforce to this effort
E VG S M U N

4.b.1 Comments:

c) Government Property Control
E VG S M U N

4.c.1. Comments:

d) Knowledge/expertise demonstrated by contractor personnel
E VG S M U N

4.d.1. Comments:

e) Utilization of Small Business concerns
E VG S M U N

4.e.1. Comments:

f) Ability to simultaneously manage multiple projects with multiple disciplines
E VG S M U N

4.f.1. Comments:

g) Ability to assimilate and incorporate changes in requirements and/or priority, including planning, execution and response to Government changes
E VG S M U N

4.g.1. Comments:

h) Effectiveness of overall management (including ability to effectively lead, manage and control the program)
E VG S M U N

4.h.1. Comments:

5. COST/FINANCIAL MANAGEMENT

a) Ability to meet the terms and conditions within the contractually agreed price(s)?
E VG S M U N

5.a.1. Comments:

b) Contractor proposed innovative alternative methods/processes that reduced cost, improved maintainability or other factors that benefited the client
E VG S M U N

5.b.1. Comments:

c) If this is/was a Government cost type contract, please rate the Contractor’s timeliness and accuracy in submitting monthly invoices with appropriate back-up documentation, monthly status reports/budget variance reports, compliance with established budgets and avoidance of significant and/or unexplained variances (under runs or overruns)
E VG S M U N

5.c.1. Comments:

d) Is the Contractor’s accounting system adequate for management and tracking of costs? If no, please explain in Remarks section.
Yes No

5.d.1. Comments:

e) If this is/was a Government contract, has/was this contract been partially or completely terminated for default or convenience or are there any pending terminations? Indicate if show cause or cure notices were issued, or any default action in comment section below.
Yes No

5.e.1. Comments:

f) Have there been any indications that the contractor has had any financial problems? If yes, please explain below.
Yes No

5.f.1 Comments:

6. SAFETY/SECURITY

a) To what extent was the contractor able to maintain an environment of safety, adhere to its approved safety plan, and respond to safety issues? (Includes: following the users rules, regulations, and requirements regarding housekeeping, safety, correction of noted deficiencies, etc.)
E VG S M U N

6.a.1 Comments:

b) Contractor complied with all security requirements for the project and personnel security requirements.
E VG S M U N

6.b.1. Comments:

7. GENERAL

a) Ability to successfully respond to emergency and/or surge situations (including notifying COR, PM or Contracting Officer in a timely manner regarding urgent contractual issues).
E VG S M U N

7.a.1. Comments:

b) Compliance with contractual terms/provisions (explain if specific issues)
E VG S M U N

7.b.1. Comments:

c) Would you hire or work with this firm again? (If no, please explain below)
Yes No

7.c.1. Comments:

d) In summary, provide an overall rating for the work performed by this contractor.
E VG S M U N

7.d.1. Comments:

Please provide responses to the questions above (if applicable) and/or additional remarks. Furthermore, please provide a brief narrative addressing specific strengths, weaknesses, deficiencies, or other comments which may assist our office in evaluating performance risk (please attach additional pages if necessary):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________STRENGTHS:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________WEAKNESSES:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ DEFICIENCIES:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ COMMENTS:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Past Performance Information provided by: __________________________________________________ (Printed Name)

Signature: ________________________________________ Date: ____________________________ Organization: _____________________________________ Phone: ____________________________

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