Attachment 12 - Past Performance Survey (3 pages).docx
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- Attached to
- Y1DB--Expand Interventional Radiology Suite Federal contract opportunity
- Solicitation number
- 36C24823R0162
About this file
This document is a past performance survey template for federal contractors to submit references on previous similar contracts for evaluation. It requests information on a minimum of three and maximum of five past performance projects, including contractor details, contract numbers and award dates, project titles and locations, prime contractor or subcontractor role, percentage of work performed, description of scope of work and roles, reasons for project selection, performance periods with start and completion dates, difficulties encountered and resolutions, completion status and reasons for non-completion, contract values with original and final prices and explanations for differences, and notices of any terminated contracts and reasons. The related federal contract opportunity is a solicitation from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8 to expand an interventional radiology suite, identified by solicitation number 36C24823R0162 and named "Y1DB--Expand Interventional Radiology Suite."
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PAST PERFORMANCE SURVEY SHEET
PROJECT NO. [ ] Page 1 A minimum of three (3) and a maximum of five (5) past performance projects.
a. Contractor Information of awarded contract (Firm Name, Address, Unique Entity Identifier ID, and Cage Code, Phone number (include area code), POC Name, POC email, Company email)
b. Contract and/or Task Order Number and Award Date (mm/dd/yyyy)
c. Project Title/Name and Location
d. Work Performed as: Prime Contractor, Subcontractor, Joint Venture, Other (explain):
e. Percent (%) of project work performed by your company
f. If you work as subcontractor, who was the prime?
(Firm Name, Address, Unique Entity Identifier ID, and Cage Code, Phone number, POC Name, POC email, Company email)
g. Government Agency/Company which awarded contract to offeror, and Contact Information, such Contracting Officer/Procurement Official/COR/Point of Contact/ (Name, Title, Email, Phone Number).
PAST PERFORMANCE SURVEY
| PAST PERFORMANCE SURVEY SHEET | |
| PROJECT NO. [ | ] Page 2 |
h. Description of project’s scope of work and the offeror’s specific roles and responsibilities in the project: Describe work performed in sufficient detail to permit evaluation of project relevancy to this procurement. Detail how work performed is relevant to the effort required by the solicitation? Use continuation sheet for additional information, if necessary.
| PAST PERFORMANCE SURVEY SHEET | |
| PROJECT NO. [ | ] Page 3 |
i. Explanation of why the projects were selected as the same or similar and how the experience obtained on the submitted project is pertinent to the execution of this project.
j. Describe any difficulties and/or obstacles encountered during performance; steps taken toward resolution. Describe unforeseen conditions and how each were resolved
k. Performance Period, including contract start date (mm/dd/yyyy), and original completion date (mm/dd/yyyy), if not completed, projected date (mm/dd/yyyy)
| Contract Start Date: |
| Original Completion Date, if not completed, projected completion date (mm/dd/yyyy) |
l. Actual Completion Date (mm/dd/yyyy), and if not completed, why?
Actual Completion Date:
If not completed, Why?
m. Project is 50% or more complete? YES [ ] No [ ]. If “No” explain percentage of completion, if not 50% completed for any reason, rating may be lower.
n. The Offerors shall indicate if any of the contracts listed were terminated and the type and reasons for the termination.
o. Original Contract Price (Award Amount), Final Contract Price (to include all modifications, if applicable), Explain Differences.
Original Contract Price: Final Contract Price:
Explain Differences:
File details come from the government source that posted it. Updated .