Attachment 14-Past Performance Questionnaire 1-20-2026.pdf
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- Solicitation number
- 36C26026R0040
About this file
This is a Past Performance Questionnaire template for the Department of Veterans Affairs (DVA), Portland VA Medical Center, for contract 36C26026R0040 titled "Correct Electrical FCA Deficiencies." The document serves as an evaluation instrument for assessing contractor past performance as part of the source selection process for this federal contract opportunity.
The questionnaire instructs offerors to prepare and distribute reference questionnaire packages to each project they cite as a past performance reference, with completed forms to be returned to the DVA by February 19, 2026, via email to toni.wiser@va.gov and colleen.nicholson@va.gov. The reference package must include a cover letter, respondent information rating sheets with the offeror's name on every page, and optionally a pre-addressed stamped envelope. Reference contacts are instructed to complete the form in full and return it directly to the specified email addresses. The questionnaire evaluates contractor performance across multiple categories using a 0-5 scale (Neutral to Exceptional): Quality Management & Workmanship (six criteria including quality control processes, personnel qualifications, submittal clarity, and problem-solving approaches); Timeliness and Adherence to Schedule (three criteria addressing schedule notices, submittal timeliness, and progress schedule compliance); Business Practices/Customer Relationship and Ability to Perform (five criteria covering problem-solving initiative, independent work capability, subcontractor management, permitting coordination, and change order proposal timeliness); Compliance & Safety (four criteria including reporting accuracy, federal compliance, safety program implementation, and infection control processes); and Overall Customer Satisfaction (three yes/no questions regarding modification reasonableness, cure notices, and willingness to award future contracts). The respondent must provide an overall performance rating and detailed remarks, then certify the accuracy of responses under penalty of perjury.
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PAST PER FORMANCE QUESTIONNAIRE
PAST PERFORMANCE QUESTIONNAIRE
INSTRUCTIONS TO OFFEROR FOR SENDING REFERENCE QUESTIONNAIRE
FORMS: Prepare and send a reference questionnaire package for each project you list as a reference for the Past Performance evaluation factor. You are encouraged to send a questionnaire to other clients of contracts. For Government contracts, send to Contracting Officer or Technical Representative. For commercial references send to personnel with duties similar to those for Government contracts. It is your responsibility to follow-up and to encourage your references to send in their questionnaire. If you have multiple references at one location, send one cover letter and questionnaire for each contract you want a reference for. Your questionnaire package should contain the following.
Cover Letter (See SAMPLE TRANSMITTAL LETTER) Respondent Info Rating Sheets Offeror should put name in spaces indicated and ensure it is on every page for identification purposes Suggested - Pre-Addressed stamped envelope to return to Contracting Officer.
SAMPLE TRANSMITTAL LETTER
Your Company Letterhead Date: _________________ To: ______________________________________ We have listed your firm as a reference for the work we have performed for you as listed below. Our firm has submitted a proposal under a project advertised by the Department of Veterans Affairs- Portland VA Medical Center.
In accordance with Federal Acquisition Regulations (FAR), they will evaluate our firm's past performance. Your candid response to the attached questionnaire will assist the evaluation team in this process. We understand that you have a busy schedule and your participation in this evaluation is greatly appreciated.
Please complete the enclosed questionnaire as thoroughly as possible. Space is provided for comments. Understand that while the responses to this questionnaire may be released to the offerer, complete confidentiality will be maintained. Only one response from each office is required.
Please send the completed questionnaire to the following email address on 2-19-2026. email to:
toni.wiser@va.gov and colleen.nicholson@va.gov
If you have questions regarding the attached questionnaire, or require assistance, please contact Toni Wiser at the above email address. Thank you for your assistance Please be advised that “E-Mail” is the preferred method of receiving the requested information.
Department of Veterans Affairs Portland VA Medical Center
PAST PERFORMANCE QUESTIONNAIRE FOR: 36C26026R0040 Correct Electrical FCA Deficiencies
INSTRUCTIONS TO OFFEROR
Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and submit it according to the instructions, below.
Company Name Street Address
Point of Contact
(POC)
City
POC Phone Number State Reference Project Title
Zip Code
Contract Period of Performance (start to finish):
Contract Number Contract Dollar Value
Description of Work
Role of Contractor on This Project (check appropriate box)
Prime Contractor Sub-contractor Key Personnel
INSTRUCTIONS TO REFERENCE CONTACT
The contractor named above is submitting a proposal for a United States Department of Veterans Affairs contract and has sent this form to you as a past performance reference contact. Please complete the following pages in full (all areas shaded in light yellow, below). Once completed, please send the form directly to the email below:
Email address: toni.wiser@va.gov and colleen.nicholson@va.gov
Please return the completed form ASAP, but no later than 2-19-2026.
If you have any questions, please contact the Contract Specialist: toni.wiser@va.gov
SOURCE SELECTION SENSITIVE WHEN COMPLETED*****NOT TO BE RELEASED
OUTSIDE GOVERNMENT CHANNELS***** RETURN THIS PAGE WITH QUESTIONAIRE
RESPONDENT INFORMATION [completed by Reference Contact]
Company Name Street Address
POC Name City
Phone Number State
Email Zip Code
PERFORMANCE INFORMATION: Choose the number on the scale of 0 (Neutral) to 5 (Exceptional) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE AN EXPLANATION FOR THE OVERALL RATING in the Remarks section, below.
0 1 2 3 4 5
NEUTRAL UNACCEPTABLE MARGINAL ACCEPTABLE VERY GOOD OUTSTANDING
No record of past performance, or not applicable or the record is inconclusive.
Performance did not meet most contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective.
Performance did not meet some contractual requirements.
There were problems, some of a serious nature, for which corrective action was only marginally effective.
Performance met most contractual requirements.
There were some minor problems and corrective actions taken by the contractor were satisfactory.
Performance met all contract requirements and exceeded some to the government’s benefit. There were a few minor problems, which the contractor resolved in a timely, effective manner.
Performance exceeded all contract requirements. There were no problems.
QUALITY – MANAGEMENT & WORKMANSHIP
1.
How well did the Offeror utilize quality control process that ensured conformance to scope and quality requirements?
2.
Demonstrated ability to hire, maintain, and replace, if necessary, qualified construction personnel during the contract period.
3.
Provided and followed approved quality control plan and/or inspection procedures to meet contract requirements.
4.
Corrected deficiencies in timely manner and pursuant to their quality control procedures.
5.
Submittals clearly identified the proposed item IAW the specifications and drawings.
6. Suggested alternative approaches to problems.
TIMELINESS AND ADHERENCE TO SCHEDULE
0 1 2 3 4 5
7.
Contractor provided timely notices of possible delays/schedule revisions.
REMARKS:
8.
Timeliness in submitting submittals and reports and responding to agency inquiries, RFP's, etc.
REMARKS:
9. Developed realistic and met approved progress schedules.
BUSINESS PRACTICES/CUSTOMER RELATIONSHIP AND ABILITY TO PERFORM
10.
Displayed initiative to solve problems.
REMARKS:
11.
How well did the contractor work independent of Government guidance, oversight and assistance?
REMARKS:
12.
Subcontractors / tradesmen were adequately managed and coordinated. Explain any subcontracting issues (positive or negative) that impacted the performance of your contract(s).
REMARKS:
13.
Contractor independently coordinated with state and city permitting/environmental agencies, public safety departments, and public utility companies.
14.
For contract changes, contractor provided timely and realistic change order proposals.
COMPLIANCE & SAFETY
0 1 2 3 4 5
15.
Reports (i.e., daily, test, logs) / records were submitted completely and accurately satisfy the requirement.
16.
Applicable to Federal Contracts –Contractor complied with applicable Federal Laws and Regulations such as Construction Wage Rate Requirements – timely payrolls and compliance; Drug-Free Workplace; Environmental Regulations and Use of Recovered Materials; Executive Order 13101 Greening the Government.
17.
Contractor’s safety program was in compliance with federal regulations. Contractor implemented and followed their safety plan and ran a “safe jobsite”.
INFECTION CONTROL
18.
Contractor had an Infection Control Process in place and complied with agency Infection Control Requirements.
REMARKS:
OVERALL CUSTOMER SATISFACTION
19. Demonstrated reasonableness in modifications cost proposal.
20.
Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.”
YES NO
21.
Would you award another contract to this contractor? If not, please explain in “remarks.”
YES NO
OVERALL PERFORMANCE RATING:
REMARKS (Please use as much space as is needed – the box will expand as you type).
I hereby certify that the information that I have reported above is accurate to the best of my knowledge.
Printed Name E-mail address
Business Title Signature Date
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