36C79118R0006-010.docx

ATTACHMENT 9

PAST PERFORMANCE QUESTIONNAIRE

Project/Contract: _________________________ Name of Offeror: _______________________________

Name and Title of Person Completing Questionnaire: ________________________________________

Company/Organization: _________________________________________________________________

Briefly describe the nature and size in dollars of your contract with the Offeror and types of hearing aid repairs/services and models covered (If more space is needed, please use the “Additional Comments” block on the second page):

Please return this Past Performance Questionnaire to: Department of Veterans Affairs; Denver Acquisition and Logistics Center; Attn: Contracting Office; Reference VA791-13-P-0003; PO Box 25166; Denver, CO 80225-0166.

ADJECTIVAL RATING DEFINITIONS

Past Performance Question

Rating (Circle answer)

1. Describe the quality of work the performed by the contractor.

Comments:

Acceptable / Unacceptable

2. Describe the extent to which the contractor adhered to the schedule.

3. How responsive was the contractor in resolving quality, schedule, or other contract issues?

ATTACHMENT “4”

PAST PERFORMANCE QUESTIONNAIRE (CONTINUATION)

4. Was the contractor effective in addressing specific customer needs?

Yes / No

5. How satisfied were you with the contractor’s overall performance?

Satisfied / Not Satisfied

6. Would you award another contract to this contractor?

Yes / No

ADDITIONAL COMMENTS:

PLEASE NOTE: In accordance with Federal Acquisition Regulations, contractors may be advised of adverse remarks and given an opportunity to respond. However, the contracting officer will not provide your name or copies of this questionnaire to the contractor or any other party not directly involved in the evaluation of the contractor’s proposal.