Attachment 5- Optional Past Performance Questionnaire.docx

VHA NETWORK CONTRACTING OFFICE 20 ● 1601 E. FOURTH PLAIN BLVD BLDG. 17, SUITE B428 ● VANCOUVER, WA

PAST PERFORMANCE QUESTIONNAIRE (PPQ)

SECTION 1

CONTRACT INFORMATION – Contractor 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 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.

HOW IS THIS PROJECT RELEVANT TO PROJECT OF SUBMISSION? Click or tap here to enter text.

SECTION 2

EVALUATOR INFORMATION – Client to complete

Veterans Health Administration (VHA) Regional Procurement Office-West (RPOW) Network Contracting Office 20 (NCO 20) is considering the offeror identified above for award of a construction project to renovate multiple buildings for mental health services.

Your comments would be appreciated regarding this company’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 accuracy of the information in Section 1 and complete the questionnaire as thoroughly as possible. NCO 20 may contact you to obtain any additional information regarding a contract award. This form should be completed for the client for whom the offeror directly did work for.

Please return your completed questionnaire to the offeror to be incorporated into the offeror submission. PPQs should NOT be submitted directly to NCO 20 as a separate submission. Refer to the solicitation for submission due date.

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.

*Please see Page 4 for Adjectival Ratings for the following:

1. QUALITY

2. SCHEDULE/ TIMELINESS OF PERFORMANCE

3. COMMUNICATION

4. MANAGEMENT/ PERSONNEL/ LABOR

5. COST/ FINANCIAL MANGEMENT

6. SUBCONTRACT MANAGEMENT

Ability to manage subcontracting effort, including any subcontracting issues, and the contractor’s ability to resolve the problems without extensive customer guidance

Choose an item.

Comments:

7. SUMMARY

ADDITIONAL COMMENTS:

ADJECTIVAL RATINGS AND DEFINITIONS TO BE USED TO BEST REFLECT YOUR EVALUATION OF THE CONTRACTOR’S PERFORMANCE

Rating Definition

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