ATTACHMENT 3 - Past Performance Questionnaire.docx
DOCX document 44 KB Posted
- Solicitation number
- 36C77026R0004
About this file
This document is a Past Performance Questionnaire for the Department of Veterans Affairs (VA) Network Contracting Office, specifically for a pharmaceutical repackaging services contract (Solicitation Number 36C77024R0010). The form is designed to collect detailed performance feedback from previous contractors, with references required to complete and submit the questionnaire by 5:00 PM Central Time on Monday, June 2nd, 2025, to Contract Specialist Renee Kreutzer.
The questionnaire evaluates contractors across 20 performance metrics using a 0-5 rating scale, covering areas such as personnel management, quality control, problem-solving, schedule adherence, and cooperation. Key components include assessing the contractor's ability to provide experienced managers, maintain qualified personnel, follow quality control procedures, meet project schedules, and respond to contract changes. The form also includes critical yes/no questions about cure notices and willingness to re-award a contract, with space for detailed remarks and a certification of accuracy by the reference contact.
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Text version
Department of Veterans Affairs Network Contracting Office (NCO 15) CMOP Acquisitions 3450 S. 4th Street Trafficway Leavenworth, KS 66048
Past Performance Questionnaire
INSTRUCTIONS TO CONTRACTOR
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
City
Point of Contact 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 to the Contract Specialist via postal mail or email directly to:
Department of Veterans Affairs Network Contracting Office 15 ATTN: Renee Kreutzer, Contract Specialist REF: 36C77024R0010, Repacker Services 3450 S. 4th Street Trafficway Leavenworth, KS 66048 Email Address: renee.kreutzer@va.gov
Please return the completed form no later than 5:00PM Central Time, Monday, June 2nd, 2025. If you have any questions, please contact the Contract Specialist, Renee Kreutzer, via email. Thank you for your assistance in this matter.
RESPONDENT INFORMATION [completed by Reference Contact]
Company Name (company rating contractor)
Street Address
POC Name
City
Phone Number
State
Fax Number
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 (text box will expand to whatever extent is necessary).
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| NEUTRAL |
| UNSATISFACTORY |
| MARGINAL |
| SATISFACTORY |
| GOOD |
| EXCEPTIONAL |
| No record of past performance or the record is incon-clusive. |
| Performance did not meet most contractual require-ments. 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. |
| The Contractor … |
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| 1. |
| Provided experienced managers and/or supervisors with the technical and administrative abilities needed to meet contract requirements. |
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| 2. |
| Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel throughout the contract period. |
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| 3. |
| Delegated authority to project managers and supervisors commensurate with contract requirements. |
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| 4. |
| Home office participated in solving significant local problems. |
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| 5. |
| Followed approved quality control plan. |
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| 6. |
| Provided effective quality control and/or inspection procedures to meet contract requirements. |
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| 7. |
| Corrected deficiencies in timely manner and pursuant to their quality control procedures. |
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| 8. |
| Provided timely resolution of contract discrepancies |
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| 9. |
| Identified problems as they occurred. |
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| 10. |
| Suggested alternative approaches to problems. |
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| 11. |
| Displayed initiative to solve problems. |
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| 15. |
| Met established project schedules. |
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| 16. |
| Was responsive to contract changes. |
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| 18. |
| Paid subcontractors in a timely manner, if applicable. |
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| 20. |
| Cooperated with Company/Government personnel after award. |
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| 21. |
| Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.” |
| |_| |
| YES |
| |_| |
| NO |
| 22. |
| Would you award another contract to this contractor? If not, please explain in “remarks.” |
| |_| |
| YES |
| |_| |
| NO |
| 23. |
| OVERALL PERFORMANCE RATING: |
| |_| 0 |
| |_| 1 |
| |_| 2 |
| |_| 3 |
| |_| 4 |
| |_| 5 |
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 image1.png
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