Past Performance Fill In Sheet -12-10-25.docx
DOCX document 24 KB Posted
- Attached to
- NATIONAL OPERATIONAL/MAILING SUPPLIES
- Solicitation number
- 36C77025R0004_2
About this file
This document is a Past Performance Fill In Sheet for a Department of Veterans Affairs contract (Solicitation Number 36C77025R0004_2). The contract is a five-year Indefinite Delivery/Indefinite Quantity (IDIQ) agreement to provide operational and mailing supplies for seven CMOP (Consolidated Mail Outpatient Pharmacy) locations. The form is designed for contractors to obtain reference evaluations, with references rating performance across multiple dimensions including product quality, delivery, communication, and invoicing using a 0-5 scale. The reference contact is asked to provide detailed information about the contractor's performance, including dollar value, period of performance, services provided, and whether they would award another contract to the same contractor.
The solicitation, managed by the Veterans Health Administration Veterans Integrated Service Network 15, includes a recent amendment modifying requirements for Child Resistant Clear Medical Pouches, expanding the sample case requirement from 1 to 10 cases. The past performance form allows potential contractors to demonstrate their capabilities by collecting third-party evaluations, with the completed references serving as evidence of their performance history and reliability in meeting contract requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| S02 - PRICING SCHEDULE - OP SUPPLIES - 36C77025R0004_2_12-10-25.xlsx | XLSX spreadsheet | |
| FREQUENTLY ASKED QUESTIONS - 12-10-25.pdf | ||
| Attachment Subcontracting Plan Template.docx | DOCX document | |
| S02 - PRICING SCHEDULE - OP SUPPLIES - 36C77025R0004_2_11-25-25.xlsx | XLSX spreadsheet | |
| S02 - 36C77025R0004_2 - NAT OP SUPPLIES IDIQ - 11-25-25.pdf |
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Text version
Attachment 6 – Past Performance INSTRUCTIONS TO PRIME CONTRACTOR: (Contractor submitting proposal):
Complete the CONTRACTOR INFORMATION section. Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and submit it according to the instructions, below.
Company Name
Street Address
Point of Contact
City
Point of Contact Phone Number
State
E-Mail Address
Zip Code
| Solicitation Number |
| 36C77025R0004_2 |
| Description of Work |
| This is a five year IDIQ contract to support all seven(7) CMOP locations with Operational (Mailing) Supplies. |
INSTRUCTIONS TO REFERENCE CONTACT
The contractor named above is submitting a proposal for a United States Department of Veterans Affairs contract and has sent this form to you as a past performance reference contact. Please complete the following pages in full (all areas shaded in light yellow, below). Once completed, please return the form to vendor requesting the reference:
RESPONDENT INFORMATION [completed by Reference Contact] Government Agency or Company name
Street Address
POC Name
City
Phone Number
State
Fax Number
Zip Code
Contract Number
Prime or Subcontractor
Dollar Value
Period of Performance
Description of services provided
Location of services provided
Number of FTEE YOUR FIRM provided
PERFORMANCE INFORMATION: Choose the number on the scale of 0 (Neutral) to 5 (Exceptional) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE AN EXPLANATION FOR THE OVERALL RATING in the Remarks section, below (text box will expand to whatever extent is necessary).
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| NEUTRAL |
| UNSATISFACTORY |
| MARGINAL |
| SATISFACTORY |
| GOOD |
| EXCEPTIONAL |
| No record of past performance or the record is incon-clusive. |
| Performance did not meet most contractual require-ments. There were serious problems and the contractor’s corrective actions were ineffective. |
| Performance did not meet some contractual requirements. There were problems, some of a serious nature, for which corrective action was only marginally effective. |
| Performance met most contractual requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory. |
| Performance met all contract requirements and exceeded some. There were a few minor problems, which the contractor resolved in a timely, effective manner. |
| Performance exceeded all contract requirements. There were no problems. |
| The Contractor … |
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| 1. |
| Quality of Product called for in the contract |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 2. |
| Delivery of supplies / Product IAW the Contract |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 3. |
| Communication; |
-- Delivery delays (If applicable) was timely --Request from site for delivery changes – Responded in a timely manner
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 4. |
| Invoicing – Submitted Invoices timely and as called out in the contract |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 16. |
| Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.” |
| |_| |
| YES |
| |_| |
| NO |
| 17. |
| Would you award another contract to this contractor? If not, please explain in “remarks.” |
| |_| |
| YES |
| |_| |
| NO |
| 18. |
| OVERALL PERFORMANCE RATING: |
| |_| 0 |
| |_| 1 |
| |_| 2 |
| |_| 3 |
| |_| 4 |
| |_| 5 |
REMARKS (Please use as much space as is needed – the box will expand as you type).
I hereby certify that the information that I have reported above is accurate to the best of my knowledge.
Printed Name
E-mail address
Business Title
Signature
Date
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