36C78618Q0247-003.doc

National Cemetery Administration

Oakland Memorial Service Network

1301 Clay Street, Suite 1230 North Oakland, CA 94612-5209

PAST PERFORMANCE QUESTIONAIRE

Please complete this questionnaire by circling a letter that corresponds to the performance level. Legible handwritten narrative responses are sufficient. Explanation of evaluation codes is as follows:

CODE PERFORMANCE LEVEL:

E EXCEPTIONAL – The contractor’s performance clearly exceeds contractual requirements.

S SATISFACTORY – No problems exist, or only minor problems for which solutions were in hand.

M MARGINAL – Problems exist for which there is doubt whether the identified solution is adequate, but the problem appears to be within the contractor’s ability to solve.

U UNSATISFACTORY-Did not perform the minimum requirements of the agreement/contract.

N NOT APPLICABLE – Unable to provide a score

3. Circle the appropriate letter for each item on the questionnaire and provide narrative justification.

4. Email completed questionnaire to Joseph Mendoza at joseph.mendoza1@va.gov Joseph M. Mendoza

Contract Officer

National Cemetery Administration

Pacific District

1301 Clay Street, Suite 1230 North Oakland, CA 94612-5209

(510) 637-6287 Solicitation:

Contractor:

Date:

Overall Score:

Reference 1:

Contact person:

Email sent

1. Is the contract for:

2. What was/is the period of this contract?

3. What is the estimated contract dollar amount?

4. How would you rate the quality of service?

5. Were they responsive to requirements as set forth in solicitation?

6. Were they responsive to correct problems in a timely manner?

7. What is you overall satisfaction with service performance?

8. OVERALL:

Notes:

Reference 2:

VA Loma Linda Contact person:

Phone conversation:

1. Is the contract for:

2. What was/is the period of this contract?

3. What is the estimated contract dollar amount?

4. How would you rate the quality of service?

5. Were they responsive to requirements as set forth in solicitation?

6. Were they responsive to correct problems in a timely manner?

7. What is you overall satisfaction with service performance?

8. OVERALL:

Notes:

Reference 3:

Contact person:

Phone conversation:

1. Is the contract for?

2. What was/is the period of this contract?

3. What is the estimated contract dollar amount?

4. How would you rate the quality of service?

5. Were they responsive to requirements as set forth in solicitation?

6. Were they responsive to correct problems in a timely manner?

7. What is your overall satisfaction with service performance?

8. OVERALL:

Notes: