Attachment 05 - Past Performance Questionnaire.docx

VA PROGRAM CONTRACTING ACTIVITY CENTRAL ● 6100 OAK TREE BLVD SUITE 490 ● INDEPENDENCE, OH 44131

PAST PERFORMANCE QUESTIONNAIRE (PPQ)

PPQs should be provided back to the requestor to incorporate into their proposal. All PPQs should be included in the proposal submission by the offeror. The PPQ does not count toward the page limitation listed in the Instructions to Offerors.

SECTION 1

CONTRACT INFORMATION – Requester to complete #1-3

1. CONTRACTOR INFORMATION

NAME OF OFFEROR BEING EVALUATED: Click or tap here to enter text.

ADDRESS: Click or tap here to enter text.

POINT OF CONTACT: Click or tap here to enter text.

CONTACT PHONE NUMBER: Click or tap here to enter text.

CONTACT EMAIL ADDRESS: Click or tap here to enter text.

WORK PERFOMED AS: Click or tap here to enter text.

PERCENT OF PROJECT WORK PERFORMED: Click or tap here to enter text.

IF SUBCONTRACTOR, WHO WAS THE PRIME? Click or tap here to enter text.

2. CONTRACT INFORMATION

CONTRACT TITLE: Click or tap here to enter text.

CONTRACT NUMBER AND DO/TO NUMBER: Click or tap here to enter text.

CONTRACT TYPE: Choose an item.

if other:

CONTRACT LOCATION: Click or tap here to enter text.

AWARD DATE: Click or tap to enter a date.

ORIGINAL CONTRACT ACCCEPTANCE (construction accepted) Date: Click or tap to enter a date.

ACTUAL CONTRACT ACCEPTANCE: Click or tap to enter a date.

EXPLAIN DIFFERENCES: Click or tap here to enter text.

ORIGINAL IMPLEMENTATION PRICE: Click or tap here to enter text.

ORIGINAL CONTRACT PRICE (all costs - design/installation/financing): Click or tap here to enter text.

FINAL CONTRACT PRICE (including modifications, if applicable): Click or tap here to enter text.

EXPLAIN DIFFERENCES: Click or tap here to enter text.

3. PROJECT DESCRIPTION

SCOPE INCLUDED IN PROJECT: Click or tap here to enter text.

SECTION 2

PERFORMANCE INFORMATION – Client to complete

Veterans Health Administration (VHA) Program Contracting Activity Central (PCAC) is evaluating the Offeror identified above for award of an IDIQ for construction services in VISN 8 Caribbean.

Your comments would be appreciated regarding this firm’s past performance. The intent of this form is to evaluate the company’s ability to perform the work as described in the solicitation.

Please verify the information in Section 1 is accurate and complete the enclosed questionnaire as thoroughly as possible. In addition to submitting this questionnaire, VHA PCAC may contact you in order to obtain any additional information.

Please email your completed questionnaire back to the firm requesting prior to the date listed in the Solicitation as they will need these completed documents to incorporate into their proposal for submission.

*Submissions made after this date and time will not be accepted or evaluated.

EVALUATOR INFORMATION

NAME OF EVALUATOR: Click or tap here to enter text.

POSITION: Click or tap here to enter text.

ADDRESS: Click or tap here to enter text.

PHONE: Click or tap here to enter text.

EMAIL: Click or tap here to enter text.

DESCRIBE YOUR ROLE IN THE PROJECT: Click or tap here to enter text.

PERFORMANCE INFORMATION:

Please evaluate the past performance using only the following ratings without variation. If the rating is other than Satisfactory, please provide additional information in the comments block or in the remarks section of this form.

E = Exceptional V = Very Good S = Satisfactory M = Marginal U = Unacceptable N/A = Not Applicable

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Additional Remarks: Please use this space to indicate anything else you would like to say about the contractor being referenced or to list anything you especially liked or disliked about this contractor:

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