ATTACHMENT 5 - Past Performance Questionnaire.docx
DOCX document 34 KB Posted
- Solicitation number
- 36C24826Q0673
About this file
This is a Past Performance Questionnaire template designed for the Department of Veterans Affairs (VA) to evaluate contractor performance on the Lake Baldwin Pharmacy Hazardous Mixing Room construction project (Solicitation 36C24826Q0673). The questionnaire must be completed by the contractor's previous clients and submitted to Contracting Officer Elizabeth Romero at aldwyn.singleton@va.gov no later than June 4, 2026, with the subject line referencing the solicitation number and company name.
The questionnaire collects contractor information including company details, project history, contract value, and contract number, followed by client/reference contact information. The performance evaluation section uses a 1-5 rating scale (Exceptional, Very Good, Marginal, Unsatisfactory, Neutral) across multiple categories: Management (experienced personnel, hiring and retention, onsite supervision, cooperation, employee conduct, subcontractor management); Quality Control (adherence to quality plans, product/material/equipment quality, timely deficiency corrections, submittals); Regulations (compliance with drawings, specifications, design guidelines, material specifications); Problem Resolution; Schedule (timeline adherence, submittal timeliness, progress reporting, punch list completion); and Warranty Response. Respondents must provide narrative explanations for any ratings of 3 or 2, identify the contractor's two best performance traits, and answer whether they would award another contract to the contractor and whether the contractor is rated in CPARS. This template serves as an evaluation tool for past performance in support of the Orlando Veterans Affairs Medical Center's approximately 850 square foot pharmacy renovation project requiring design and construction services compliant with USP Chapter 797 and Section 800 standards.
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Text version
FOR OFFICIAL USE ONLY
CONTRACTOR’S PAST PERFORMANCE QUESTIONNAIRE
INSTRUCTIONS TO CONTRACTOR
1. Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes).
2. The entire cover sheet and questionnaire should be forwarded to your previous clients. The questionnaire shall cover projects identified in the evaluation factors (Experience, Past Performance and Technical Qualifications) of the Offeror’s proposal.
3. Send an electronic or hard copy of the form to each of your reference contacts.
INSTRUCTIONS TO CLIENT/REFERENCE CONTACT
1. The contractor named below is submitting an offer for a Department of Veterans Affairs (VA) contract requirement. The purpose of this form is to obtain your assessment of the Contractor's performance on contracts performed for you by the Contractor. The VA is seeking to determine whether the Offeror has experience that will enhance their technical capability to perform and whether the Offeror consistently delivers quality services in a timely and cost-effective manner.
2. Clients shall submit the completed questionnaire via email to Elizabeth Romero, Contracting Officer at aldwyn.singleton@va.gov no later than the offer due date {JUNE 4, 2026} of the solicitation. Please reference “Solicitation 36C24826Q0673/Past Performance/Company Name” in the subject field of your email.
GENERAL INFORMATION [completed by Contractor]
Contractor/Company Name
Street Address
Contractor Point of Contact Name
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 |_| Subcontractor |_| Joint Venture |_| Other (Explain)
CLIENT/RESPONDENT INFORMATION [completed by Reference Contact]
Company Name
Street Address
POC Name
City
Phone Number
State
Fax Number
Zip Code
PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 5 that most accurately describes the Contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 3 OR 2 in the Remarks section, below [text box will expand to whatever extent is necessary].
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
| Exceptional |
| Very Good |
| Marginal |
| Unsatisfactory |
| Neutral |
| Performance met all contract requirements and EXCEEDED many to the government’s benefit. Problems, if any, were negligible and were resolved in a timely, highly effective manner. |
| 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 did not meet some contractual requirements. There were problems, some of a serious nature, for which corrective action was only marginally effective. |
| Performance did not meet most contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective. |
| No record of past performance or the record is inconclusive. |
| Management |
| 5 |
| 4 |
| 3 |
| 2 |
| 1 |
| Provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements. |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period. |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Effectiveness of onsite management and supervision |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Level of cooperation and responsiveness to the Government |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Professional conduct of the employees |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| How effective was the contractor in managing Subcontractors? |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Quality Control |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Followed approved Quality Control Plan |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Overall quality of products, material and equipment installed |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
Corrected deficiencies in timely manner and pursuant to their quality control procedures
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Timely Correction of noted deficiencies |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Corrected deficiencies in timely manner and pursuant to their quality control procedures |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Accuracy, adequacy and details of Submittals |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Regulations |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| To what level did the contractor follow drawings, specifications and regulations and guidance such as the VA Technical Information Library (TIL) |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| To what level would you rate the contactor’s ability to follow Design Guidelines |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| How would you rate the contractors’ use of specified material? |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Problem Resolution |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| How effective is the contractor in resolving problems and correcting deficiencies in timely manner? |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Schedule |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| To what level did the contractor meet approved and established schedules |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Rate the Contractor’s submission of submitted submittals in a timely manner |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Submission of progress schedules, invoices and daily reports |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Completion of punch list items |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Warranty Response |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| What level would you rate the contractor’s response to warranty support? |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| What was the level of cooperation with the Government personnel after award? |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| How would you rate the contractor's overall performance? |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| Recommendations |
| NO |
YES
| Would you award another contract to this contractor? If not, please explain in “remarks.” |
| ☐ |
| To the best of your knowledge, is the contractor rated in CPARS for this contract? |
| ☐ |
REMARKS [Please use as much space as is needed – the box will expand as you type].
What are the two best performance traits this contractor displayed during the period of performance?
1.
2.
3. Other Comment
Date [mm/dd/yyyy]: _______________________________
Client’s Print Name: _______________________________
Client’s Signature: _________________________________
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