Attachment C_Past Performance Questionnaire Form.docx

VA PAST PERFORMANCE QUESTIONNAIRE

CONTRACT INFORMATION (Contractor/Offeror to complete Blocks 1-4)

1. CONTRACTOR/OFFEROR INFORMATION

Past Performance Reference No. (1-5):

Offeror Name:

Address:

Phone Number: DUNs Number:

Contact Name:

Email Address: Contact Phone Number:

3. CONTRACT INFORMATION

Contract Number:

Contractor Name Reference Contract Awarded To: Contractor DUNS Awarded: Agency/Customer:

Delivery/Task Order Number (if applicable):

Contract Type: Firm Fixed Price Cost Reimbursement Other (Please explain) Contract Title:

Contract Location:

Award Date (mm/dd/yy):

Construction Completion Date (mm/dd/yy):

Awardee Ongoing Services:

Original Contract Price (Award Amount):

Final Contract Price (to include all modifications, if applicable):

REFERENCE INFORMATION

Past Performance Questionnaire Reference Name & Title:

Phone No.:

Email:

Address:

Contracting Officer (CO) or Individual Responsible for Signing Contract Name & Title:

Phone No.:

Email:

Address:

Resident Engineer/CO’s Technical Representative or Construction Supervisor Name & Title:

Phone No.: Email: Address:

Solicitation No.:

Project Title:

ORP PAST PERFORMANCE QUESTIONNAIRE (CONTINUED)

4. PROJECT DESCRIPTION

Type of Work (check all that apply): VA Federal Medical Office Other: Reference Project Key Personnel Assigned as Key to Solicitation Project: Yes No If yes, please provide key personnel names and roles:

DETAILED DESCRIPTION OF THE WORK PERFORMED

EXPLANATION OF RELEVANCY TO SOLICITATION REQUIREMENTS

INSTRUCTIONS FOR REFERENCES COMPLETING THIS QUESTIONNAIRE: VA requests that the reference completes this questionnaire and submits it directly back to [INSERT CONTRACTING POC] no later than 4:00 PM EST on [INSERT DATE] with a subject line that reads [Solicitation Number] - [Name of Offeror], Completed Past Performance Questionnaire”. The government reserves the right to verify all information on this form. To select: click box and fill shape in black.

Use the following adjective ratings and definitions in your evaluation of the Contractor’s performance.

TO BE COMPLETED BY PPQ REFERENCE

PPQ REFERENCE

PPQ Reference Point of Contact Information Name:

Title:

Agency/Company:

Phone Number:

Email Address:

Contract No.:

Contract Type:

Contract Title: Contract Location:

Describe your role in the project:

Does the narrative in No. 4, above, accurately describe the scope, complexity, and relevance (Y/N):

Date Questionnaire was completed (mm/dd/yy):

PPQ Reference’s Signature:

Instructions: Please select the adjective rating that best reflects your evaluation of the contractor’s performance.

(a) Quality of construction, workmanship, quality of materials used, interior and overall appearance.

(b) Ability to meet quality standards specified for technical performance.

(c) Timeliness/effectiveness of contract problem resolution without extensive customer guidance.

(d) Adequacy/effectiveness of quality control program and adherence to contract quality assurance requirements (without adverse effect on performance).

(a) Compliance with contract delivery/completion schedules including any significant intermediate milestones. (If the schedule was not met, please address below.)

(b) Rate the contractor’s use of available resources to accomplish tasks identified in the contract.

(c) Rate your satisfaction with the contractor’s ability to respond to questions and/or comments in a timely manner.

(a) To what extent were the end users satisfied with the project?

(b) Contractor was reasonable and cooperative in dealing with your staff (including the ability to successfully resolve disagreements/disputes; responsiveness to administrative reports, businesslike and communication).

(c) To what extent was the contractor cooperative, businesslike, and concerned with the interests of the customer?

(d) Overall customer satisfaction.

Solicitation No.:

Project Title:

(a) Effectiveness of management, including management of subcontractors and/or labor force?

(b) Ability to hire, apply, and retain a qualified workforce to this effort.

(c) Government Information Property Control.

(d) Knowledge/expertise demonstrated by contractor key personnel.

(e) Government contract requiring a subcontracting plan (Complete if the contractor was required to submit and adhere to a small business subcontracting plan. Were small business goals met?

(f) Ability to simultaneously manage multiple projects with multiple disciplines.

(g) Ability to assimilate and incorporate changes in requirements and/or priority, including planning, execution and response to Government changes.

(h) Effectiveness of overall management (including ability to effectively lead, manage and control the project).

(a) Ability to meet the terms and conditions within the contractually agreed price(s)?

(b) Contractor proposed innovative alternative methods/processes that reduced cost, improved maintainability or other factors that benefited the PM.

(c) Is the Contractor’s accounting system adequate for management and tracking of costs? (If no, please explain in comment section below.)

(d) If this is/was a Government contract, has/was this contract been partially or completely terminated for default or convenience or are there any pending terminations? (Indicate if show cause or cure notices were issued, or any default action in comment section below.)

Yes

No

(e) Have there been any indications that the contractor has had any financial problems? (If yes, please explain in the comment section below.)

(a) To what extent was the contractor able to maintain an environment of safety, adhere to its approved safety plan, and respond to safety issues? (Includes: following the users rules, regulations, and requirements regarding housekeeping, safety, correction of noted deficiencies, etc.).

(b) Contractor complied with all general and IT security requirements for the project and personnel security requirements.

(a) Ability to successfully respond to emergency and/or surge situations (including notifying COR, PM or Contracting Officer in a timely manner regarding urgent contractual issues).

(b) Compliance with contractual terms/provisions (If there were specific issues, please explain in the comments sections below

(c) In summary, provide an overall rating for the work performed by this contractor.

8. SUMMARY

COMMENTS SECTION

Please provide responses to the above questions (if applicable) and/or additional remarks. Also, please provide a brief narrative addressing specific strengths, weaknesses, deficiencies, or other comments which may assist our office in evaluating performance risk (please attach additional pages if necessary):

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