ATTACHMENT D.4 - PAST PERFORMANCE SURVEY.pdf

D.4 Attachment Past Performance Survey

Past Performance Form version 1.1 p. 1 of 3

PAST PERFORMANCE SURVEY

A. GENERAL INFORMATION:

Contractor's Name:_____________________________________________________

Contractor’s Address:___________________________________________________

Contract #:____________________________________________________________

Contract Dollar Value #:_________________________________________________

Contract POP:_________________________________________________________

COTR:_______________________________________________________________

COTR’s Ph #:__________________________________________________________

Contracting Officer:_____________________________________________________

Contracting Officer’s Ph #:_______________________________________________

B. Services Performed:

C. PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 6 that most accurately describes the contractor's performance or situation.

1 - Unsatisfactory. Performance did not meet most contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective.

2 - Marginal. Performance did not meet some contractual requirements. There were problems and the contractor’s corrective actions were ineffective.

3 - None. No record of past performance or the record is inconclusive.

4 - Satisfactory. Performance met contract requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory.

5 - Very Good. Performance met all contract requirements and exceeded some to the government’s benefit. There were few minor problems which the contractor resolved in a timely, effective manner.

6 - Exceptional. 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 efficient manner.

Surveys shall be returned directly to the Contract Specialist, Dayna Cantu at dayna.cantu@va.gov from the CO/COR, no later than 06/10/2024 at 10:00am CDT.

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Past Performance Form version 1.1 p. 2 of 3

E. Please provide comments for all questions in which an Unsatisfactory or Marginal rating is given and as appropriate for all other answers. Space for your comments is provided in each area. If more space is needed, attach additional sheets to the end of the questionnaire and reference the respective question.

TO BE COMPLETED BY THE DELEGATED COTR

The contractor:

1. Provided experienced/qualified personnel to perform services.

1 2 3 4 5 6 N/A

Remarks______________________________________________________________________

2. Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period. Also provide coverage with qualified personnel during periods of leave or absence .

1 2 3 4 5 6 N/A

Remarks_____________________________________________________________________

3. Met established schedules.

1 2 3 4 5 6 N/A

Remarks______________________________________________________________________

4. Cooperated with Government personnel after award.

1 2 3 4 5 6 N/A

Remarks______________________________________________________________________

5. Provided timely resolution of contract discrepancies

1 2 3 4 5 6 N/A

Past Performance Form version 1.1 p. 3 of 3

Remarks_____________________________________________________________________

6. Performed work that met or exceeded acceptable levels.

1 2 3 4 5 6 N/A

Remarks_____________________________________________________________________

7. Suggested alternative approaches to problems.

1 2 3 4 5 6 N/A

Remarks______________________________________________________________________

8. Displayed initiative to solve problems.

1 2 3 4 5 6 N/A

Remarks______________________________________________________________________

9. Would you recommend award of another contract to this contractor? Yes No

Remarks_____________________________________________________________________

Signature of CO/COTR date