Attachment E - Past Performance Questionnaire.docx
DOCX document 34 KB Posted
- Solicitation number
- 36C26126R0028
About this file
This is a Past Performance Questionnaire template designed for contractors bidding on GSA Schedule 36C26126R0028, a construction services solicitation for the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21. The questionnaire serves as an evaluation tool to assess bidders' relevant experience and qualifications for the project.
The questionnaire applies to solicitation Z2DA--570-20-308, which concerns the replacement and expansion of chilled water infrastructure in Building 1 at Veterans Affairs Palo Alto Health Care System (VAPAHCS) located at 3801 Miranda Avenue, Palo Alto, California. While the primary contract opportunity involves renovation and expansion of the Sterile Processing Department to create separate spaces for Sterile Processing Service and Supply Chain Service with improved workflow and controlled access, the past performance questionnaire is a standard evaluation component used to verify contractor capability, relevant project experience, quality of work, schedule adherence, and financial stability on similar federal construction projects.
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36C26126R0028 Expand Chilled Water 570-20-308
PAST PERFORMANCE QUESTIONNAIRE INSTRUCTIONS
OR RENOVATION VA Northern California Healthcare System, Mather, California
The information obtained from this questionnaire will be utilized to evaluate the past performance of offerors submitting proposals in response to the 36C26126R0028, Replace and Expand Chilled Water Infrastructure. The information you provide will be instrumental in allowing the Government to evaluate how well the contractor performed under your contract(s).
a. Please complete all sections of the attached questionnaire. Include your name and title, organizational address, e-mail address, telephone and fax number.
b. Include the contractor’s name, your point of contact (POC,) the title and/or description of the type of work performed the award number, the value of the contract, the award and completion date of the project and the type of award.
c. Use the attached rating scale rate each performance element.
d. Comments are encouraged and would be appreciated. The last page may be used if additional space is needed for comments. Clear handwritten responses are sufficient.
e. Due to time constraints, it is important that the questionnaire be completed and returned by the date proposal is due (June 1, 2026, at 10:00 am Pacific Time). Please e-mail your response with the RFP/RFQ numbers as the subject line and send to charee.harris@va.gov.
Thank you for your time and participation.
PAST PERFORMANCE RATING SCALE
| RATING: |
| DEFINITION: |
| USAGE: |
| EXCEPTIONAL |
| Performance exceeded many contractual requirements to the Government’s benefit. The contractual performance of the element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were highly effective. |
| An EXCEPTIONAL rating is appropriate when the contractor successfully performed multiple significant events that were of benefit to the Government/Owner. A singular benefit however could be of such magnitude that it alone constitutes an Exceptional rating. Also there should have been NO significant weaknesses identified |
| GOOD |
| Performance exceeded some contractual requirements to the Government’s benefit. The contractual performance of the element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were effective. |
| A GOOD rating is appropriate when the contractor has successfully performed a significant event that was a benefit to the Government/Owner. There should have been no significant weaknesses identified. |
| SATISFACTORY |
| Performance met all contractual requirements. The contractual performance of the elements being assessed were accomplished with no more than a few minor problems for which corrective actions taken by the contractor were satisfactory. |
| A SATISFACTORY rating is appropriate when there were only a few minor problems, or major problems that the contractor recovered from without impact to the contract. There should have been NO significant weaknesses identified. |
| MARGINAL |
| Performance did not meet some contractual requirements. The contractual performance of the element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully successful. |
| A MARGINAL rating is appropriate when a significant event occurred that the contractor had trouble overcoming which impacted the Government/Owner. |
| UNSATISFACTORY |
| Performance did not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element contains a serious problem(s) for which the contractor’s corrective actions were ineffective. |
| An UNSATISFACTORY rating is appropriate when multiple significant events occurred that the contractor had trouble overcoming and which impacted the Government/Owner. A singular problem, however could be of such serious magnitude that it alone constitutes an unsatisfactory rating. |
| Neutral/Not Applicable or Unknown |
| No performance record identifiable within the area of evaluation |
| Performance was not observed or not applicable to the current effort being reported. |
PAST PERFORMANCE QUESTIONNAIRE
NAME OF CONTRACTOR BEING EVALUATED:
CONTRACTOR MAIN POC
CONTRACT NUMBER:
CONTRACT VALUE:
| CONTRACTOR PERFORMED WORK AS: |
| CONTRACT AWARD & COMPLETION DATE: |
Prime Contractor Sub- Contractor Key Personnel
PROJECT TITLE AND BRIEF DESCRIPTION OF WORK:
RESPONDENT’S NAME
YOUR ORGANIZATIONAL ADDRESS
PHONE/FAX NO:
E-MAIL:
1. QUALITY:
| A. Quality of technical data/report preparation efforts |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| B. Ability to meet quality standards specified for technical performance |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| C. Timeliness/effectiveness of contract problem resolution without extensive customer guidance |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| D. Adequacy/effectiveness of quality control program and adherence to contract quality assurance requirements (without adverse effect on performance) |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
FOR OFFICIAL USE ONLY – SOURCE SELECTION SENSITIVE WHEN COMPLETED
2. SCHEDULE/TIMELINESS OF PERFORMANCE:
| A. Compliance with contract delivery/completion schedules including any significant intermediate milestones |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| B. Rate the contractor’s use of available resources to accomplish tasks |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
3. CUSTOMER SATISFACTION:
| A. To what extent were the end users satisfied with the project? |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| B. Contractor was reasonable and cooperative in dealing with your staff (including the ability to successfully resolve disagreements/disputes; responsiveness to administrative reports and business communication) |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| C. To what extent was the contractor cooperative, businesslike and concerned with the interests of the customer? |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| D. Overall customer satisfaction |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
4. MANAGEMENT/PERSONNEL/LABOR
| A. Effectiveness of on-site management, including management of subcontractors, suppliers, materials and/or labor force? |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
FOR OFFICIAL USE ONLY – SOURCE SELECTION SENSITIVE WHEN COMPLETED
| B. Ability to hire, apply and retain a qualified workforce to the effort |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| C. Government Property Control |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| D. Knowledge/expertise demonstrated by contractor personnel |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| E. Ability to simultaneously manage multiple projects with multiple disciplines. |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| F. Ability to assimilate and incorporate changes in requirements or priority, including planning, execution and response to Government changes |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| G. Effectiveness of overall management (including ability to effectively lead, manage and control the program) |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
5. COST/FINANCIAL MANAGEMENT
| A. Ability to meet the terms and conditions contractually agreed to price(s)? |
| RATING |
| E |
| E |
| E |
| E |
| E |
| E |
Comments:
FOR OFFICIAL USE ONLY – SOURCE SELECTION SENSITIVE WHEN COMPLETED
| B. Contractor proposed innovative alternative methods/processes that reduced costs, improved maintainability or other factors that benefited the client. |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| C. If this is/was a Government cost type contract, please rate the contractor’s timeliness and accuracy in submitting monthly invoices with appropriate backup documentation, monthly status reports/budget variance reports, compliance with established budges and avoidance of significant and/or unexplained variances (under runs or overruns) |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| D. Have there been any indications that the contractor has had any financial problems? If yes please explain below |
| RATING |
| Yes |
| No |
Comments:
6. SAFETY/SECURITY:
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.)
RATING
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| B. Contractor complied with all security requirements for the project and personnel security requirements. |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
FOR OFFICIAL USE ONLY – SOURCE SELECTION SENSITIVE WHEN COMPLETED
7. GENERAL:
| 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.) |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
| B. Compliance with contractual terms/provisions (explain if specific issues) |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
C. Would you hire or work with this firm again (if no, please explain below)
RATING
| Yes |
| No |
| D. In summary, provide an overall rating for the work performed by this contractor. |
| RATING |
| E |
| G |
| S |
| M |
| U |
| N |
Comments:
FOR OFFICIAL USE ONLY – SOURCE SELECTION SENSITIVE WHEN COMPLETED
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