S02_Attachment 0006_RFP 36C79126R0011_Offeror Past Performance Questionnaire_Fillable.docx

ATTACHMENT 0006 - PAST PERFORMANCE QUESTIONNAIRE

DEPARTMENT OF VETERANS AFFAIRS (VA)

ETMPM-TENS Procurement Program Solicitation Number 36C79126R0011

Past Performance Questionnaire (PPQs)

Purpose: Offerors responding to Solicitation Number 36C79126R0011 shall submit up to three (3) CPARS Evaluation Reports when available. The Government Evaluators will validate the availability of CPARS Evaluation reports utilizing the Offeror’s System for Award Management (SAM.gov) Unique Entity Identifier (UEI) for any Offeror that utilizes a PPQ. When an Offeror cannot provide at least three (3) CPARS evaluation reports with effective dates in the past 24 - 36 months, the Offeror shall submit up to three (3) completed PPQs from recent/relevant Customers for similar medical device supply contracts. Note: Any combination of CPARS Evaluation Reports and PPQs shall be utilized to ensure that the Offerors’ proposal submission documentation includes three (3) past performance documents for Government evaluations. This is a material proposal submission requirement and may not be waived by the Government.

Instructions For The Rater / Customer (How to complete this PPQ): Please provide information for contracts performed within the last three (3) years that demonstrate the Offeror’s capability to perform the medical‑device supply work required under Solicitation Number 36C79126R0011. A separate Attachment 0006 shall be completed for each contract or order presented as a past-performance reference. Evaluate the Offeror’s performance as follows:

1. Scope & Period: Evaluate the Offeror’s performance during the most recent 24–36 months of the referenced contract(s), addressing device quality, delivery timeliness, warranty/RMA support, customer‑service responsiveness, labeling and traceability, and regulatory compliance.

2. Adjectival Ratings: Select one rating for each evaluation area (Exceptional, Very Good, Satisfactory, Marginal, Unsatisfactory, or N/A) and provide narrative evidence supporting each rating. CPARS definitions and standards apply.

3. Numeric Mapping: Each adjectival rating has a numeric equivalent (5 = Exceptional; 4 = Very Good; 3 = Satisfactory; 2 = Marginal; 1 = Unsatisfactory; N/A = No Score). This mapping assists the VA evaluation team but does not replace qualitative judgment under FAR 15.305 and FAR 15.308.

4. Narratives Are Mandatory: A supporting narrative is required for every substantive rating. For an N/A selection, the Rater should briefly state why the area is inapplicable. Every selected rating must include a detailed narrative describing specific performance evidence such as dates, quantities, defect rates, timeliness statistics, corrective actions, and measurable outcomes. Ratings without narratives cannot be used.

5. Certification & Digital Signature: Please complete the certification block and apply a digital signature. CPARS practice requires documented, signed input from the Rating Official.

6. PPQ Submission Requirements: After completing and digitally signing the PPQ, convert it to a PDF and email the signed PDF directly to the VA Contract Specialist identified in the solicitation at email address john.overstake@va.gov and carbon copy “cc” the EPO AS4D Contracting Officer at email address maurice.walker@va.gov. The PPQ must be received by the VA on or before the common response date for the receipt of all proposals due-in date and time. The VA Contract Specialist will issue an acknowledgment of receipt for each PPQ to ensure transparency and tracking to the Customer/Rater and the Offeror. Although PPQs must be electronically transmitted directly by the Customer/Rater to the VA via an email message and the PPQ document attached to the email message, the Offeror is ultimately responsible for ensuring that all required PPQs are submitted to the VA by the common response date for the receipt of all proposals due-in date and time as stated in the solicitation.

SECTION A - OFFEROR & CONTRACT REFERENCE (Completed by Offeror, validated by Rater):

Offeror (Company Legal Name / UEI / CAGE): ____________________________________

Contract/Order Number(s): ____________________________________

Agency/Customer Organization: ____________________________________

Period of Performance (From–To): ____________________________________ Contract Type: ☐ FFP Supply; ☐ IDIQ; ☐ BPA/BOA; ☐ FSS/GSA; or ☐ Other:

Description of Supplies:(e.g., portable TENS units; IFC devices; neuromodulation devices for headache disorders; short‑wave diathermy; electrodes; lead wires; chargers; accessories):

Total Contract/Order Value: $____________________________

Rater Name / Title / Organization: ____________________________________

Rater Email / Phone: ________________________________________________________________ Relevancy Confirmation (Rater / Customer): The above referenced supplies are similar in scope and complexity to VA’s ETMPM/TENS devices and accessories requirements (CLINs X001–X005). ☐ Yes; or ☐ No

SECTION B - QUICK REFERENCE: CPARS DEFINITIONS

Select one rating in each area & provide a thorough narrative that supports the assigned ratings. CPARS rating scale:

· Exceptional = 5pts.

· Very Good = 4 pts.

· Satisfactory = 3 pts.

· Marginal = 2 pts.

· Unsatisfactory = 1 pt.

Complete the seven (7) contract performance rating areas below:

(Use these definitions to guide rating selection and narratives.)

Narrative Expectations (Mandatory Entries): Every rating must be supported by specific, factual, time‑bound evidence (e.g., delivery on 10/12/2025 missed by 5 days; 2.3% defect rate in Base Year; 100% on‑time urgent orders in OY1; 48‑hour RMA turnaround; FDA 510(k) documentation provided; BAA/TAA certifications provided). FAR 15.305 requires documented assessments of Contractor’s performance; CPARS Evaluation Reports instructions to Rating officials consistently emphasize the requirement for robust narratives that support the assigned evaluation area rating.

B.1 QUALITY OF PRODUCT (SUPPLY):

What to consider:

· Device conformance to specifications/Minimum Technical Requirements (MTRs), FDA 510(k) clearance, workmanship, reliability/durability in clinical use, safety features, accessories completeness, packaging integrity, labeling/serialization & barcode traceability.

· Warranty/RMA handling: speed, effectiveness, no‑cost replacements, defect rates at delivery/first use.

· End‑user feedback (clinicians/Veterans); acceptance/rejection rates; measurable quality trends. (Adapted from CPARS “Quality”; supply emphasis added.)

Select Rating: (Check one (1) of the below boxes to indicate rating) ☐ Exceptional (5 pts.);

☐ Very Good (4 pts.);

☐ Satisfactory (3 pts.);

☐ Marginal (2 pts.);

☐ Unsatisfactory (1 pt.); or ☐ Rating Area N/A.

Narrative (required): Describe the objective evidence that supports the above rating.

B.2 SCHEDULE / DELIVERY TIMELINESS:

What to consider:

· On‑time delivery to centralized destination within the required due‑in window; early/partial shipments; backorder handling; responsiveness on urgent requests; PO acknowledgment timeliness.

· Occurrence of cure notices, delinquency letters, LDs, causes of delays, and effectiveness of corrective actions. (CPARS “Schedule” area) Select Rating: (Check one (1) of the below boxes to indicate rating) ☐ Exceptional (5 pts.);

☐ Very Good (4 pts.);

☐ Satisfactory (3 pts.);

☐ Marginal (2 pts.);

☐ Unsatisfactory (1 pt.); or

Narrative (required): Provide on‑time metrics (%), instances of late/missed deliveries, reasons, and outcomes after corrective actions.

B.3 COST CONTROL (Typically N/A for FFP supply):

· Only rate if you managed cost‑type or price‑adjustable supply actions. For FFP supplies, select N/A. (CPARS notes Cost Control is not required for fixed‑price contracts.)

Select Rating: (Check one (1) of the below boxes to indicate rating) ☐ Exceptional (5 pts.);

☐ Very Good (4 pts.);

☐ Satisfactory (3 pts.);

☐ Marginal (2 pts.);

☐ Unsatisfactory (1 pt.); or

Narrative (required if not rated N/A): Describe forecasting accuracy, pricing discipline, and any negotiated price changes during contract performance with the outcomes of those price negotiations.

B.4 MANAGEMENT / BUSINESS RELATIONS:

· Order acknowledgment, issue identification, proactive corrective action plans, responsiveness, proposal/change submittals (if applicable), cooperative behavior, customer satisfaction, subcontractor/OEM coordination, communication quality.

(CPARS “Management” area).

Select Rating: (Check one (1) of the below boxes to indicate rating) ☐ Exceptional (5 pts.);

☐ Very Good (4 pts.);

☐ Satisfactory (3 pts.);

☐ Marginal (2 pts.);

☐ Unsatisfactory (1 pt.); or

Narrative (required): Include concrete examples (e.g., rapid resolution of defects, RMA handling, OEM coordination for replacements, communication timeliness/quality).

B.5 SMALL BUSINESS SUBCONTRACTING COMPLIANCE (Rate only if applicable):

· Compliance with FAR 52.219‑8 / 52.219‑9 goals (if your contract required a subcontracting plan); good‑faith efforts; any liquidated damages related to subcontracting plan. (CPARS area guidance; Note: many medical‑device supply contracts will be N/A if the Offeror is a small business concern or if the contract type did not offer any small business utilization opportunities.)

Select Rating: (Check one (1) of the below boxes to indicate rating) ☐ Exceptional (5 pts.);

☐ Very Good (4 pts.);

☐ Satisfactory (3 pts.);

☐ Marginal (2 pts.);

☐ Unsatisfactory (1 pt.); or

Narrative (required if not rated N/A): Provide subcontracting goals established at the time of award vs. actuals achievement during contract performance, results of performance monitoring, and any corrective actions required during contract performance to correct deficiencies.

B.6 REGULATORY COMPLIANCE:

· Compliance with FDA 510(k) and medical device regulations; BAA/TAA country‑of‑origin certifications; labeling/UDI/serialization; safety/environmental regulations; anti‑trafficking; tax; reporting.

· Any suspensions/debarments, terminations, defective pricing issues, nonpayment to subcontractors/OEMs, or other adverse actions.

(CPARS “Regulatory Compliance” area adapted for medical devices.)

Select Rating: (Check one (1) of the below boxes to indicate rating) ☐ Exceptional (5 pts);

☐ Very Good (4 pts.);

☐ Satisfactory (3 pts.);

☐ Marginal (2 pts.);

☐ Unsatisfactory (1 pt.); or

Narrative (required): Cite specific compliance evidence and any issues encountered; include outcomes of corrective actions.

B.7 OTHER AREAS (If Applicable): (Rate only if applicable):

What to consider: Examples of Other Areas to be rated include: Data privacy/HIPAA handling (no PII/PHI collection), packaging/labeling quality, accuracy of invoices & EDI transactions, warranty terms execution (e.g., money‑back guarantee, no restocking fees), or training materials quality for end‑users. *(CPARS “Other Areas” - CPARS area guidance; Note: many medical device supply contracts will be N/A for “Other Areas”.)

Select Rating: (Check one (1) of the below boxes to indicate rating) ☐ Exceptional (5 pts);

☐ Very Good (4 pts.);

☐ Satisfactory (3 pts.);

☐ Marginal (2 pts.);

☐ Unsatisfactory (1 pt.); or

Narrative (required): Provide concrete examples and outcomes.

SECTION C — OVERALL ASSESSMENT & RATER’S RECOMMENDATION:

C.1 Overall Performance (Single Selection):

(Check one (1) of the below boxes to indicate rating) ☐ Exceptional (5 pts);

☐ Very Good (4 pts.);

☐ Satisfactory (3 pts.);

☐ Marginal (2 pts.); or ☐ Unsatisfactory (1 pt.).

C.2 Recommendation for Future Award: (Single Selection):

(Check one (1) of the below boxes to indicate rating) Given what I know today about the Offeror’s ability to perform in accordance with the contract’s most significant requirements, I:

☐ Would recommend this Offeror for a similar medical‑device supply contract in the future.; or ☐ Would Not recommend this Offeror for a similar contract. (CPARS certification question) Narrative (required): Explain the basis for your recommendation, referencing the most important risk drivers or strengths observed.

SECTION D — REQUIRED CERTIFICATION & DIGITAL SIGNATURE:

I certify that the information provided is accurate to the best of my knowledge and reflects first‑hand or directly verified performance observations. I understand this PPQ may be used by the VA in a source selection and contains Source Selection Sensitive Information (SSSI).

· Rater Name & Title: ____________________________________

· Organization: ____________________________________

· Email & Phone: ____________________________________

· Authorized Digital Signature: _____________________________

· Date Signed: ______________

PPQ Naming Convention: When submitting the completed Past Performance Questionnaire (PPQ), the Rater/Customer shall title the PDF attachment using the following naming convention:

“PPQ – [Offeror Legal Name] – Solicitation 36C79126R0011” This PPQ naming standard ensures accurate tracking, assignment to the correct Offeror, and proper inclusion in the VA’s Source Selection Evaluation Board (SSEB) documentation.

Submission Instructions: After fully completing all required PPQ sections, including all mandatory narratives and the digital signature certification block, please perform the following steps:

1. Convert the finalized PPQ from MS Word to a PDF document: Please convert the finalized PPQ from Microsoft Word to PDF format. Please verify that all checkboxes, ratings, and narratives appear correctly in the PDF document.

2. Document Certification Requirement: Please apply your digital signature in the certification section at the end of the PPQ. The digital signature must clearly display the Rater/Customer’s name, title/role, organization, and date of signature. This signature affirms that the information provided is accurate and reflects first-hand or directly verified observations. The Rater’s personal information in addition to the Rater’s digital signatures must clearly display:

· Rater/Customer Name;

· Title/Role;

· Organization; and

· Date of Signature.

3. Document Naming Convention Requirement: Please name the PDF document using the following format so the VA may correctly associate the PPQ with the Offeror: “PPQ – [Offeror Legal Name] – Solicitation 36C79126R0011”

4. PPQ Direct Submission By The Customer/Rater To The VA Instructions: Please Email the completed PPQ to john.overstake@va.gov and copy maurice.walker@va.gov. The VA Contract Specialist will issue an email acknowledgment for each PPQ received to ensure transparency and accurate tracking for the Offeror.

5. Email Subject Line Requirement: Please use the following subject line to ensure proper routing and tracking: “Completed PPQ Submission – [Offeror Legal Name] – Solicitation 36C79126R0011”

6. PPQ Submission Deadline: All PPQs must be received by the VA on or before the proposal due date listed in the solicitation. Although the Rater/Customer must transmit the PPQ directly to the VA, the Offeror remains ultimately responsible for ensuring that all required PPQs (up to three (3)) are submitted on time.

7. Confidentiality Notice: This PPQ contains Source Selection Sensitive Information (SSSI) and must not be released outside the VA or the Offeror’s organization for purposes of proposal evaluation. Please transmit the completed PPQ only via secure organizational email consistent with FAR 2.101 and FAR 3.104.

Policy Note: The completed PPQ is procurement-sensitive and shall be transmitted directly by the Customer/Rater to the VA. The completed evaluation should not be provided to the Offeror unless disclosure is authorized by the Government.

Closing Remarks: Thank you for taking the time to complete this Past Performance Questionnaire. Your evaluation provides essential, objective insight into the Offeror’s recent performance and enables the Department of Veterans Affairs to thoroughly assess the Offeror’s past performance when CPARS reports are unavailable. Your input helps ensure each proposal includes a minimum of three (3) reliable past performance documents, supporting informed and mission‑focused proposal evaluations and award decisions. We appreciate your contribution to this process and your assistance in helping the VA procure safe, reliable, FDA‑cleared medical devices for the Veterans we serve.

(END OF ATTACHMENT 0006 - PAST PERFORMANCE QUESTIONNAIRE)