ATTACHMENT 5 - Past Performance Questionnaire.docx

Department of Veterans Affairs: Strategic Acquisition Center (SAC)

INFORMATION REQUEST: PAST PERFORMANCE QUESTIONNAIRE

The Department of Veterans Affairs is currently in the process of awarding a competitive enterprise-wide strategic contract for Non-Invasive Transient Elastography Device. This questionnaire has been sent to you for a reference for solicitation:

Send completed questionnaires to Brian.Shepard@va.gov and John.Tarver@va.gov

Please fill the subject line of the e-mail as: [Company Name] – Past Performance Questionnaire – [ Insert Solicitation Number].

NOTE TO CONTRACTORS: If the Questionnaire is provided for Subcontractor’s reference, the contractor’s name below must include both the Prime and Subcontractor Names.

PAST PERFORMANCE QUESTIONNAIRE

Contractor’s Name:

Subcontractor’s Name (if applicable):

BPA/Contract/Task Order Number:

Name of Person Completing the Evaluation:

Telephone: E-mail:

Title:

Company/Organization:

Please rate the contractor in each of the following areas. Note: there is room for comments where you deem remarks would be helpful to our evaluation.

· Not Applicable: N/A

· 1: Performance clearly below the contract performance standard or requirement

Overall satisfaction with the Contractor’s performance.

Delivery performance includes delivery consistency, on time performance, and flexibility in responding to emerging issues and implementing required solutions.

Rate the effectiveness and applicability of the plans and strategies delivered and the actual implementation of those.

This includes the contractor’s ability to solve problems, the speed in which they handle problems, and their effective delivery of resolutions.

Rate the quality of the contractor’s staff in executing the project work scope.

7. Have you issued a cure notice, show cause notice, suspension of progress payments or other letters directing the correction of a performance problem in the past 3 years? |_| Yes |_| No If Yes, please explain.

8. Have you terminated this contractor for default within the past 3 years, or are there any pending termination actions? |_| Yes |_| No If Yes, please explain.

9. Based on the contractor’s overall performance, would you award them another contract? |_| Yes |_| No If No, please explain.

10. Have you discussed any adverse past performance problems with the Contractor and given them an opportunity to comment? |_| Yes |_| No Please explain.

11. Do you file past performance information in a database that the Contracting Officer may search? |_| Yes |_| No Please explain.

12. If the contract had options, were those options exercised? |_| Yes |_| No Please explain.

13. What was the contract period of performance (i.e., when were services provided)?

14. What was the dollar value of the contract performed by the contractor?

15. Provide a brief description of the services provided by the contractor for this contract.

Please attach any past performance database reports or other material you deem appropriate to a full understanding of the Contractor’s past performance by the evaluator. Please provide information on any adverse performance by the contractor and the corrective actions taken.