ATTACHMENT C PAST PERFORMANCE QUESTIONNAIRE.docx

ATTACHMENT C

PAST PERFORMANCE QUESTIONNAIRE

Solicitation Number: 36C24827Q0036 Acquisition ID#: 36C248-26-AP-2908 Requirement: Remove/Install Two (2) Commercial-Grade Laser/LED Projectors Issuing Agency: U.S. Department of Veterans Affairs, Network Contracting Office 8 (NCO 8) Place of Performance: Orlando VA Medical Center, 13800 Veterans Way, Orlando, FL 32827

INSTRUCTIONS

To the Offeror

1. Complete Section A – Offeror Information and Section B – Reference Contract Information below.

2. Provide this questionnaire to the customer point of contact (POC) identified by you as past performance reference.

3. Request that the POC complete Sections C through G and return the completed questionnaire directly to the VA Contracting Officer by the date identified in the solicitation.

4. Do not submit this questionnaire yourself after it has been completed by the reference. Questionnaires received from the offeror rather than directly from the reference will not be considered.

5. A minimum of two (2) and a maximum of three (3) completed questionnaires should be returned on your behalf.

To Past Performance Reference (Customer POC)

1. The offeror identified in Section A below has submitted a quotation to the U.S. Department of Veterans Affairs for a commercial audiovisual projector replacement and installation project. The VA is evaluating the offeror's past performance as part of the award decision.

2. Please complete Sections C through G based on your direct experience with the offeror on the reference contract identified in Section B.

3. Return the completed questionnaire directly to the VA Contracting Officer at the email address below by the date identified in the solicitation. Do not return the completed questionnaire to the offeror.

4. Your responses will be used solely for the evaluation of this specific acquisition and will be protected from disclosure to the maximum extent permitted by law under FAR 42.1103.

5. The questionnaire should take approximately 10–15 minutes to complete.

6. If you have questions, contact the VA Contracting Officer at the information below.

Return Completed Questionnaire To Rohan McKenzie, Contracting Officer Network Contracting Office 8 (NCO 8) Department of Veterans Affairs Email: rohan.mckenzie@va.gov Subject Line: Past Performance Questionnaire – 36C24827Q0036 – [Offeror Name] Completed questionnaires must be received by: [Response Date] at 1:00 PM Eastern Time

SECTION A – OFFEROR INFORMATION (Completed by Offeror)

Offeror Legal Name

DBA (if applicable)

UEI

Offeror Point of Contact

Phone / Email

SECTION B – REFERENCE CONTRACT INFORMATION (Completed by Offeror)

Contract / Purchase Order Number

Customer / Agency Name

Customer Point of Contact (POC) Name

POC Title

POC Phone

POC Email

Period of Performance (Start – End)

Contract Value ($)

Brief Description of Scope (2–3 sentences, including manufacturer/model installed and any Crestron integration)

SECTION C – REFERENCE VERIFICATION (Completed by POC)

POC Name (please confirm)

POC Title

Organization

Phone

Email

Date Questionnaire Completed

Length of time you have been familiar with the offeror's work (years/months)

SECTION D – SCOPE RELEVANCE (Completed by POC) Please confirm the general scope of work performed by the offeror on this contract (check all that apply):

· ☐ Commercial-grade projector supply (laser or LED)

· ☐ Projector installation and mounting

· ☐ Removal and disposal of legacy AV equipment

· ☐ Crestron control system integration and programming

· ☐ AV cabling (HDBaseT, HDMI, RS232, Ethernet)

· ☐ Image geometry/warp/blend setup

· ☐ Lens configuration and alignment

· ☐ System testing, commissioning, and end-user turnover

· ☐ After-hours or constrained-schedule installation

· ☐ Work performed in a healthcare, institutional, or similarly sensitive environment

· ☐ Other (describe): _________________________________________________ Approximate size of the installation (number of projectors or displays): ______

SECTION E – PERFORMANCE RATINGS (Completed by POC) Please rate the offeror's performance on the reference contract using the following scale:

SECTION F – NARRATIVE ASSESSMENT (Completed by POC) Please provide brief narrative responses to the following. Responses may be as detailed as you wish.

F.1 Significant Strengths. What did the offeror do particularly well on this contract?

F.2 Significant Weaknesses or Concerns. Were there any significant weaknesses, problems, or concerns with the offeror's performance? If so, please describe. Include whether the offeror took corrective action.

F.3 Contract Modifications or Disputes. Were there any significant contract modifications, cure notices, show-cause notices, claims, terminations, or disputes? If so, please describe briefly.

F.4 Would You Use This Offeror Again? Based on your experience, would you select this offeror for a similar effort?

☐ Yes, without reservation ☐ Yes, with some reservations (please explain below) ☐ No (please explain below) Explanation (if applicable):

F.5 Any Additional Information. Is there anything else the VA should know about the offeror's performance that is relevant to this type of acquisition?

SECTION G – CERTIFICATION AND RELEASE (Completed by POC) By submitting this questionnaire, I certify that:

1. The information provided above is accurate and based on my direct knowledge of the offeror's performance on the contract referenced.

2. I am an authorized point of contact for the referenced contract and am qualified to provide this assessment.

3. I understand that my responses will be used by the U.S. Department of Veterans Affairs solely for the evaluation of the offeror's past performance in connection with Solicitation 36C24827Q0036, and that responses will be protected from disclosure to the maximum extent permitted by law under FAR 42.1103(b).

PRIVACY ACT STATEMENT

Authority: 38 U.S.C. § 8127; FAR Part 42, Subpart 42.11; FAR Part 12.

Purpose: The information collected on this form is used by the U.S. Department of Veterans Affairs to evaluate the past performance of offerors competing for the referenced acquisition.

Routine Uses: Information may be shared with other Federal agencies and the offeror in accordance with FAR 42.1103 and applicable Privacy Act routine uses. Information will be protected from disclosure outside the Government to the maximum extent permitted by law.

Disclosure: Completion of this questionnaire is voluntary. Failure to complete may result in the VA being unable to consider the offeror's past performance on this contract.

END OF PAST PERFORMANCE QUESTIONNAIRE