Attachment 15-Past Performance Questionnaire.pdf
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- Solicitation number
- 36C26025R0071
About this file
The document is a Past Performance Questionnaire for a federal contract opportunity (Solicitation Number 36C26025R0071) issued by the Department of Veterans Affairs Portland VA Medical Center. The questionnaire is designed to collect detailed performance feedback from previous references about a contractor's performance, with the goal of evaluating their past performance for a potential new contract to correct electrical FCA (Facility Condition Assessment) deficiencies. The form requires references to rate the contractor on multiple dimensions including quality management, workmanship, timeliness, adherence to schedule, business practices, customer relationship, compliance, safety, and overall customer satisfaction using a 0-5 scale rating system. The completed questionnaire must be submitted via email to toni.wiser@va.gov and sandra.snediker@va.gov by Monday, August 18, 2025, at 10:00am PDT, and references are instructed to provide comprehensive remarks explaining their ratings.
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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 offeror, FAR
15.306 (e)(4) prohibits the release of the names of the persons providing the responses.
Complete confidentiality will be maintained. Only one response from each office is required.
Please send your completed questionnaire to the following email address on Monday August 18, 2025, at 10:00am PDT. Do not return them to our company.
email to: toni.wiser@va.gov and sandra.snediker@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.
VHATOGSLABYS1
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Department of Veterans Affairs Portland VA Medical Center
PAST PERFORMANCE QUESTIONNAIRE FOR: 36C26025R0071 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 sandra.snediker@va.gov
Please return the completed form ASAP, but no later than Monday, August 18, 2025, at 10:00am PDT.
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
VHATOGSLABYS1
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VHAFHMWiserT Highlight
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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