Attachment B Past Performance Questionaire fillable.pdf

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Attached to
Medication Dispensing Cabinets service agreement
Solicitation number
36C25626Q1299
Issued by

About this file

This is a Past Performance Questionnaire form designed to evaluate contractor performance on federal contracts. Respondents must return the completed questionnaire by Monday, September 28, 2026, at 12:00 p.m. Central Time to rene.impey@va.gov.

The questionnaire requires detailed information about the contractor being evaluated, including company name, address, and primary point of contact. Respondents must provide contract-specific data to determine relevancy and recency, including contract number, contract type, award date, period of performance, total contract dollar amount including options, and a brief description of services performed. Failure to provide this contract information may render a proposal unresponsive. The evaluation uses a six-point rating scale: Outstanding (O), Excellent (E), Satisfactory (S), Neutral (N), Marginal (M), and Unsatisfactory (U), with detailed definitions provided for each level. Assessments must reflect only contractor-liable performance. Respondents may circle "N" if unable to provide a rating for any area. The questionnaire evaluates five performance categories: Quality of Service (5 questions), Timeliness of Performance (4 questions), Business Relations (10 questions), and Management of Key Personnel (5 questions). Additional space is provided for handwritten remarks concerning the contractor's overall performance, and respondents must provide their printed name, title, signature, and phone number.

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Other files

File Type Posted
36C25627P0028_1.pdf PDF
S06-36C25626Q1299 0001.pdf PDF
ATTACHMENT E QASP.docx DOCX document
ATTACHMENT C CONTRACTOR CERTIFICATION.docx DOCX document
ATTACHMENT A LIST OF PAST PERFORMANCE REFERENCES.docx DOCX document
36C25626Q1299_1.pdf PDF
ATTACHMENT D NOTIFICATION OF COMPLIANCE WITH INSURANCE REQUIREMENTS.docx DOCX document
ATTACHMENT F JA_OVER_SAT revised_Redacted.pdf PDF

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Text version

ATTACHMENT B PAST PERFORMANCE QUESTIONNAIRE

RETURN BY

INSTRUCTIONS FOR THE

PAST PERFORMANCE QUESTIONNAIRE

FOR OFFICIAL USE ONLY

CONTRACTOR INFORMATION (Information on the Company that you are evaluating)

A. Contractor Name:

B. Contractor's Address:

C. Point of Contact:

CONTRACT INFORMATION:

IN ORDER TO DETERMINE RELEVANCY AND RECENCY, THE

FOLLOWING DATA IS REQUIRED. FAILURE TO PROVIDE THIS

INFORMANTION MAY RENDER THE PROPOSAL UNRESPONSIVE.

A. CONTRACT NUMBER:

B. CONTRACT TYPE:

C. AWARD DATE:

D. PERIOD OF PERFORMANCE:

E. TOTAL CONTRACT DOLLAR AMOUNT INCLUDING

OPTIONS, IF APPLICABLE: $________________

F. SCOPE: PLEASE INCLUDE A BRIEF DESCRIPTION OF THE

SERVICES PERFORMED TO DETERMINE SIMILARITY OF

SCOPE.

PAST PERFORMANCE QUESTIONNAIRE

ATTACHMENT B–PAST PERFORMANCE QUESTIONNAIRE

RETURN BY 12PM CT, Monday, Sep 28, 2026

FOR OFFICIAL USE ONLY

1. Please complete this questionnaire based on the following guidance:

a. For each question please circle one rating as defined below. Please circle "N" if you are unable to provide a rating for an area. Assessments should reflect only contractor liable performance. The following is a definition of the scoring levels:

Rating Definition Outstanding (O) High Confidence Based on the offeror’s performance record, no doubt exists that the offeror will successfully perform the required effort.

Excellent (E) Significant Confidence Based on the offeror’s performance record, essentially no doubt exists that the offeror will successfully perform the required effort.

Satisfactory (S) Confidence Based on the offeror’s performance record, little doubt exists that the offeror will successfully perform the required effort.

Neutral (N) Unknown Confidence No performance record identifiable (see FAR 15.305(a)(2)(iii) and (iv)).

Marginal (M) Little Confidence Based on the offeror’s performance record, substantial doubt exists that the offeror will successfully perform the required effort. Changes to the offeror’s existing processes may be necessary in order to achieve contract requirements.

Unsatisfactory (U) No Confidence Based on the offeror’s performance record, extreme doubt exists that the offeror will successfully perform the required effort.

b. Handwritten remarks are encouraged. Space is provided at the end of the survey. If more space is needed, please provide information of a separate sheet of paper.

c. You are urged to supplement your own knowledge of the contractor's performance with the judgment of others in your organization. In addition to completing the attached questionnaire for the identified program, we solicit your comments on other contracts/programs that your activity has with this offeror.

2. Please return completed questionnaire by e-mail to:

ATTACHMENT B PAST PERFORMANCE QUESTIONNAIRE

PAST PERFORMANCE QUESTIONNAIRE

FOR OFFICIAL USE ONLY

QUALITY OF SERVICE

1. Contractor's compliance with contractual terms and conditions. O E S N M U

2. Quality of contractor furnished reports/deliverables. O E S N M U

3. Overall rating of contractor's commitment to providing quality service. O E S N M U

4. Contractors ability to meet standards specified for performance. O E S N M U

5. Overall rating of contractor's quality of service. O E S N M U

TIMELINESS OF PERFORMANCE

1. Contractor's ability to meet specific response times and scheduled O E S N M U time frames for completion of specific tasks.

2. Contractor's responsiveness/timeliness for providing administrative O E S N M U reports/documents required by the contract.

3. Contractor's timeliness in responding to emergency service requirements. O E S N M U

4. Overall rating of contractor's responsiveness/timeliness. O E S N M U

BUSINESS RELATIONS

1. Contractor's ability to identify problems and potential problems and O E S N M U promptly notify the Contracting Officer.

2. Contractor's ability to correct problems and prevent or mitigate potential O E S N M U problems in a timely manner.

3. Contractor's willingness to improve and correct noncompliance issues O E S N M U or concerns.

4. Extent to which the contractor has demonstrated reasonable and cooperative O E S N M U behavior.

5. Contractor's ability to use effective approaches and provide technical O E S N M U expertise and resources to solve contract problems.

6. Contractor's working relationship with the Contracting Officer, O E S N M U

ATTACHMENT B – PAST PERFORMANCE QUESTIONNAIRE

quality assurance personnel, and customers.

7. Contractor's flexibility in satisfying the requirements of its customers. O E S N M U

8. Extent to which the contractor provided prompt and courteous O E S N M U service when responding to customer complaint.

9. Overall rating of customer satisfaction. O E S N M U

10. Overall rating of business relations. O E S N M U

MANAGEMENT OF KEY PERSONNEL

1. Contractor's ability to select and retain cooperative and effective O E S N M U key personnel, such as the contract manager and quality control personnel.

2. Extent key personnel were knowledgeable about contractual O E S N M U requirements.

3. Contractor's ability to meet appropriate staffing levels with qualified O E S N M U personnel in order to provide required services.

4. Contractor's ability to effectively manage subcontracts. O E S N M U

5. Overall rating of contractor's management of key personnel. O E S N M U

REMARKS CONCERNING CONTRACTOR’S OVERALL PERFORMANCE:

RESPONDENT’S PRINTED NAME: ____________________________________________

RESPONDENT’S TITLE: _____________________________________________________

RESPONDENT’S SIGNATURE: ________________________________________________

RESPONDENT’S PHONE NUMBER: ___________________________________________

FOR OFFICIAL USE ONLY

THANK YOU FOR TAKING THE TIME TO COMPLETE AND RETURN THIS QUESTIONNAIRE!

Definition
Rating
REMARKS CONCERNING CONTRACTORS OVERALL PERFORMANCE 1:
REMARKS CONCERNING CONTRACTORS OVERALL PERFORMANCE 2:
REMARKS CONCERNING CONTRACTORS OVERALL PERFORMANCE 3:
REMARKS CONCERNING CONTRACTORS OVERALL PERFORMANCE 4:
REMARKS CONCERNING CONTRACTORS OVERALL PERFORMANCE 5:
REMARKS CONCERNING CONTRACTORS OVERALL PERFORMANCE 6:
REMARKS CONCERNING CONTRACTORS OVERALL PERFORMANCE 7:
REMARKS CONCERNING CONTRACTORS OVERALL PERFORMANCE 8:
REMARKS CONCERNING CONTRACTORS OVERALL PERFORMANCE 9:
REMARKS CONCERNING CONTRACTORS OVERALL PERFORMANCE 10:
REMARKS CONCERNING CONTRACTORS OVERALL PERFORMANCE 11:
RESPONDENTS PRINTED NAME:
RESPONDENTS TITLE:
RESPONDENTS PHONE NUMBER:
Text9:
Text8:
Text7:
Text6:
Text5:
Text4:
Text3:
Text2:
Text1: Sep 28, 2026; 12:00PM CT
SCOPE 5:
SCOPE 4:
SCOPE 3:
SCOPE 2:
SCOPE 1:
E TOTAL CONTRACT DOLLAR AMOUNT INCLUDING:
Text13: Monday, Sep 28, 2026; 12:00 p.m. CT
Text14: rene.impey@va.gov

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