Attachment 5 - Past Performance Questionnaire.docx
DOCX document 169 KB Posted
- Solicitation number
- 36C26025R0015
About this file
This is a Past Performance Questionnaire template for solicitation 36C26025R0015, which is for HVAC infrastructure upgrades at the VA Medical Center in Vancouver, WA. The questionnaire is to be completed by the offeror's previous clients and submitted directly to VA contracting officers Danyel Smith and Colleen Nicholson by March 20, 2025 at 16:00 PST.
The questionnaire evaluates contractors on several key performance areas using a 0-5 rating scale: Quality Management & Workmanship, Timeliness and Schedule Adherence, Business Practices/Customer Relationship, Compliance & Safety, and Infection Control. It includes 21 specific evaluation criteria covering topics such as quality control processes, personnel management, submittal timeliness, problem-solving initiative, subcontractor management, safety compliance, and infection control procedures. The form requires detailed explanations for ratings and asks whether the reference would award another contract to the contractor. This questionnaire is part of the past performance evaluation for a contract to correct HVAC deficiencies in Building 2 Laundry/Warehouse at the Vancouver VA Medical Center.
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ATTACHMENT 4 – PAST PERFORMANCE 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. 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, 1601 E. Fourth Plain Blvd., Bldg. 17, Suite B428, Vancouver, Washington 98661. 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 no later than March 20, 2025, 16:00 PST. Do not return them to our company. E-mail them to Danyel Smith at danyel.smith@va.gov and Colleen Nicholson at colleen.nicholson@va.gov.
If you have questions regarding the attached questionnaire, or require assistance, please contact Danyel Smith at the above email address. Thank you for your assistance.
Please be advised that “E-Mail” is the method of receiving the requested information.
Department of Veterans Affairs Vancouver VA Medical Center Vancouver, WA 98661
PAST PERFORMANCE QUESTIONNAIRE FOR: 36C26025R0015 - Correct FCA HVAC Deficiencies Bldg 2 Laundry Warehouse CON
INSTRUCTIONS TO OFFEROR
Complete the CONTRACTOR INFORMATION section below (type answers into light blue shaded boxes). Save the document. Send an electronic copy 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: Danyel Smith at danyel.smith@va.gov and Colleen Nicholson at colleen.nicholson@va.gov.
Please return the completed form ASAP, but no later than March 20, 2025, 16:00 PST.
If you have any questions, please contact the Contracting Officer: Colleen Nicholson at colleen.nicholson@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
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. |
| 9. |
| Developed realistic and met approved progress schedules. |
BUSINESS PRACTICES/CUSTOMER RELATIONSHIP AND ABILITY TO PERFORM
| 10. |
| Displayed initiative to solve problems. |
| 11. |
| How well did the contractor work independent of Government guidance, oversight and assistance? |
| 12. |
| Subcontractors / tradesmen were adequately managed and coordinated. Explain any subcontracting issues (positive or negative) that impacted the performance of your contract(s). |
| 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. |
OVERALL CUSTOMER SATISFACTION
| 19. |
| Demonstrated reasonableness in modification cost proposal |
| Yes |
| No |
| 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 image1.jpg
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