ATTACHMENT 9 Past Performance Questionnaire.docx
DOCX document 103 KB Posted
- Solicitation number
- 36E77620R0048
About this file
This document contains a past performance questionnaire template and information about an upcoming federal contract opportunity for site support services for a chest x-ray system renovation project. The past performance questionnaire is a template for clients to evaluate offerors' performance on previous relevant contracts. It requests information about contract details and performance ratings in areas such as quality, schedule, communication, management, cost, safety, and subcontract management. The federal contract opportunity notice provides details about an anticipated competitive solicitation for site support services including design and construction for the renovation of an existing chest x-ray system at the Bronx VA Medical Center. Services will include site preparation, replacement of imaging equipment and associated utilities, and possible updates to examination and support areas. The small business set-aside solicitation is expected to be issued on September 15th, 2020 via request for proposal, with a 240-day period of performance and total contract value estimated between $500,000 to $1 million.
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VA PROGRAM CONTRACTING ACTIVITY CENTRAL ● 6150 OAK TREE BLVD SUITE 300 ● INDEPENDENCE, OH 44131
ATTACHMENT 9 - PAST PERFORMANCE QUESTIONNAIRE
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 IMPLEMENTATION PRICE: 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) Program Contracting Activity Central (PCAC) is considering the Offeror identified above for award of the subject project.
Your comments would be appreciated regarding this firm’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 information in Section 1 is accurate and complete the enclosed questionnaire as thoroughly as possible. Space is provided for comments. In addition to submitting this questionnaire, the VHA-PCAC may contact you in order to obtain any additional information regarding a contract award.
Please email your completed questionnaire to the Samantha.Mihaila@va.gov by the date the proposal is due.
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.
ADJECTIVAL RATINGS AND DEFINITIONS TO BE USED TO BEST REFLECT YOUR EVALUATION OF THE CONTRACTOR’S PERFORMANCE
| Rating |
| Definition |
| Outstanding |
| The Offeror’s performance met contractual requirements and exceeded many requirements to the Client’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the Offeror were highly effective |
| Above Average |
| The Offeror’s performance met contractual requirements and exceeded some requirements to the Client’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the Offeror were effective. |
| Satisfactory |
| The Offeror’s performance met contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the Offeror were satisfactory. |
| Unsatisfactory |
| Performance did not meet contractual requirements. The contractual performance reflected a serious problem for which the Offeror has yet to identify corrective actions or the Offeror’s proposed actions appear only marginally effective or were not fully implemented. |
| Not Applicable |
| No information or did not apply to your contract. |
PLEASE SELECT THE ADJECTIVAL RATING WHICH BEST REFLECTS YOUR EVALUATION OF THE CONTRACTOR’S PERFORMANCE.
1. QUALITY
| Ability to meet quality design and/or construction standards specified for technical performance |
| Choose an item. |
| Comments: |
2. SCHEDULE/ TIMELINESS OF PERFORMANCE
| Compliance with contract delivery/completion schedules including timely submission of data deliverables (If liquidated damages were assessed or the schedule was not met, please address below.) |
| Choose an item. |
| Comments: |
3. COMMUNICATION
| Contractor was reasonable and cooperative in dealing with client staff (including the ability to successfully resolve disagreements/ disputes; and responsiveness to client requests) |
| Choose an item. |
| Comments: |
4. MANAGEMENT/ PERSONNEL/ LABOR
| Effectiveness of management, including suppliers, materials, and/or labor force (including the ability to effectively lead, manage, and control the project) |
| Choose an item. |
| Continuity in the contractor’s personnel during execution of the contract (e.g., one person or team that stayed with the project throughout the contract) |
| Choose an item. |
| Comments: |
5. COST/ FINANCIAL MANGEMENT
| Ability to meet the terms and conditions within the contractually agreed price? |
| Choose an item. |
| Comments: |
6. SAFETY/ SECURITY
| Ability the to maintain an environment of safety, adhere to its approved safety plan, and respond to safety issues. (Includes following the user’s rules, regulations, and requirements regarding housekeeping, safety, correction of noted deficiencies, etc.) |
| Choose an item. |
| Comments: |
7. 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:
8. SUMMARY
| Would you hire or work with this firm again? If no, please explain below. |
| Choose an item. |
| Provide an overall rating for the work performed by this contractor. |
| Choose an item. |
ADDITIONAL COMMENTS:
| EVALUATOR SIGNATURE: |
| DATE: |
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