ATTACHMENT D.6 - PAST PERFORMANCE QUESTIONNAIRE.docx
DOCX document 22 KB Posted
- Solicitation number
- 36C24925R0054
About this file
This document is a Past Performance Questionnaire for a VA contract solicitation for Plastic Surgery Physician Services. The solicitation (RFP 36C24925R0054) is being issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9, with a performance period from 10/1/25 to 9/30/30. The questionnaire is designed to systematically evaluate a contractor's past performance across multiple dimensions, including contract compliance, personnel appropriateness, schedule adherence, responsiveness, and reliability.
The evaluation form uses a standardized rating scale from "Outstanding" (O) to "Unacceptable" (U) across ten key performance criteria. Evaluators are asked to provide detailed ratings and comments on areas such as contract requirement compliance, reporting accuracy, personnel quality, performance scheduling, flexibility, technical responsiveness, and overall reliability. The completed questionnaire is to be sent directly to the contracting specialist, Laura Edelman, via email, and will serve as a critical component in assessing potential contractors for the Plastic Surgery Physician Services contract.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Attachment D.6 – Past Performance Questionnaire
RFP 36C24925R0054
PAST PERFORMANCE QUESTIONNAIRE
REFERENCE INSTRUCTIONS: The Network Contracting Office 9 is soliciting for award of a VA contract for Plastic Surgery Physician Services. Your comments would be appreciated regarding this firm’s past performance. The intent of this form is to evaluate contractors who have provided Plastic Surgery Physician Services in the past.
Survey must be completed by evaluator and sent to the contracting specialist, Laura Edelman via email at laura.edelman@va.gov.
Information of Company to be Evaluated
| Company name: | ________________________________ | ||
| Address: | ________________________________ | ||
| ________________________________ | |||
| Phone: | ________________________________ | ||
| Email: | ________________________________ |
Information of Evaluating Agency
| Evaluator’s name: | ________________________________ | ||
| Title: | ________________________________ | ||
| Agency name: | ________________________________ |
Information regarding your Contract with the company to be evaluated:
| Estimated Contract Amount: | ________________________________ | |
| Contract Period of Performance: | ________________________________ | |
| Type of Services rendered: | ________________________________ |
Please evaluate the past performance using only the following ratings without variation. Provide additional information in the appropriate block or in the remarks section of this form to justify your ratings.
“O” = Outstanding = Performance greatly exceeded the contract requirements
“A” = Above Average = Performance exceeded the contract requirements
“S” = Satisfactory = Performance met the contract requirements
“M” = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory
“U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements
| Please rate and provide information/comments for the following: |
| Circle one |
Q1. To what extent did the contractor comply with contract requirements?
O A S M U
Q2. If reports were required, were they accurate in meeting contract requirements?
O A S M U
Q3. To what extent did the contractor use appropriate personnel for contract requirements?
O A S M U
| Please rate and provide information/comments for the following: |
| Circle one |
Q4. To what extent was contractor able to meet the performance schedule:
O A S M U
Q5. What extent was contractor flexible in responding to changing needs?
O A S M U
Q6. To what extent was the contractor reliable?
O A S M U
Q7. To what extent was the contractor responsive to technical directions?
O A S M U
Q8. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, please explain.
Yes No
Q9. Would you award another contract to the party being evaluated? If no, please explain:
Yes No
Q10. To what extent did contractor notify you of problems or potential problems?
O A S M U
11. Please describe services provided under your contract, period of performance and total cost:
12. Additional Remarks:
Signature of Evaluator
Date
File details come from the government source that posted it. Updated .