ATT O - Past Performance Questionnaire.pdf

Past Performance Questionnaire

OFFEROR INSTRUCTIONS: A separate record must be completed for each Past Performance Questionnaire; Offeror must directly send to the evaluator, requesting they complete and return as indicated on this document no later than, December 12, 2024, at 12:00 PM CST to rich.hedman@va.gov with copy to orita.jarvis@va.gov. Further, Offeror must include a copy of each requested Past Performance Questionnaire with proposal submission.

Name of Offeror being evaluated:

Address of Offeror:

Contract Details (i.e. Contract #/ Delivery or Task Order #, Title, Location, etc)

Evaluator’s Name:

Evaluator’s Position held or function in relation to project:

Evaluator’s Company/Organization Name, Address and Phone number:

Evaluator’s email address:

Attachment O mailto:rich.hedman@va.gov mailto:orita.jarvis@va.gov VHAMIWHedmaJ Highlight

Past Performance Survey

Instructions: The Department of Veterans Affairs is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation (FAR) 15.506 prohibits the release of the names of the individuals providing reference information about the Offeror’s past performance. Survey should be completed by the evaluator and returned to rich.hedman@va.gov with copy to orita.jarvis@va.gov,no later than the above date.

Please evaluate the Past Performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, provide additional information in the appropriate block or in the remarks section of this form.

O = Outstanding = Performance greatly exceeded contract requirements A = Above Average = Performance exceeded contract requirements S = Satisfactory = Performance met contract requirements M = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory.

U = Unacceptable = Performance was poor and/or did not satisfy contract requirements

Please describe the project the firm requesting this survey performed for you.

Dates of service (from, to):

Rate the following questions if the company provided outpatient clinic construction/leasing/property management or similar services. Provide information/comments in the Remarks Section below.

Circle One

Q1. To what extent did the contractor comply with contract requirements? O A S M U

Q2. How timely was the contractor’s performance? O A S M U

Q3. How well did the contractor comply with the labor and safety standards? O A S M U

Q4. Rate the effectiveness of the contractor’s management of the contract? O A S M U

Attachment O mailto:rich.hedman@va.gov mailto:orita.jarvis@va.gov

Q5. Rate the contractor’s personnel relationship management practices – how well did the contractor’s personnel interact and work with Government representatives?

O A S M U

Q6. Quality Control: Rate the overall quality of contractor’s work.

O A S M U

Q7. What extent was contractor flexible in responding to changing needs?

O A S M U

Q8. To what extent was the contractor reliable?

O A S M U

Q9. To what extent was the Contractor responsive to technical directions?

O A S M U

Q10. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, explain on the following page.

Yes No

Q11. Would you award another contract to this contractor? If no, explain on the following page.

Q12. Was the customer satisfied with the service provided? If no, explain on the following page.

Q13. To what extent did contractor notify you of problems of potential issues?

O A S M U

Q14. Was the contractor professional and courteous in its interaction with you? Yes No

Q15. Did the contractor respond promptly to requests? Yes No Q16. Did the contractor meet all expectations under the contract? Yes No

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Past Performance Survey – Remarks Section

Evaluator’s Additional Remarks regarding services:

Signature of Evaluator: Date of Evaluation:

Print Name of Evaluator:

Please DO NOT return survey to the company you are evaluating.

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