ATTACHMENT D.6 PAST PERFORMANCE SURVEY.pdf

PAST PERFORMANCE SURVEY

Past Performance Form version 1.1 1 of 4

36C25725Q0870

D.5 PAST PERFORMANCE SURVEY

Past Performance Surveys must be completed by the organization (reference) that has direct knowledge of the Offeror’s performance on previous contracts.

Completed surveys shall be sent directly from the reference organization (not the Offeror) via email to both of the following addresses:

Shannon.hodgson@va.gov Dayna.cantu@va.gov

A. GENERAL INFORMATION:

Contractor's Name:

Contractor’s Address:

Contract #:

Contract Dollar Value:

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.

mailto:Francisco.Mendoza@va.gov mailto:Stephanie.Reeves@va.gov

Past Performance Form version 1.1 2 of 4

36C25725Q0870 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.

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 COR

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______________________________________________________________________

36C25725Q0870

Past Performance Form version 1.1 3 of 4

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 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_____________________________________________________________________

Past Performance Form version 1.1 4 of 4

36C25725Q0870

Signature of COR date

Return surveys to Shannon Hodgson at Shannon.hodgson@va.gov AND Dayna Cantu at Dayna.cantu@va.gov, NLT 12/09/2025 as stated on the SF1449 page 1 block 8 or as indicated on solicitation amendments if an extension to the proposal due date is issued.

mailto:Francisco.mendoza@va.gov mailto:stephanie.reeves@va.gov VHASTXHodgsS1 Highlight

D.5 PAST PERFORMANCE SURVEY