ATTACHMENT F_Past Performance Questionnaire_36C10X26Q0110.docx
DOCX document 41 KB Posted
- Solicitation number
- 36C10X26Q0110
About this file
This is a Past Performance Questionnaire template used by the Department of Veterans Affairs Strategic Acquisition Center to evaluate offerors responding to Solicitation No. 36C10X26Q0110 for Non-Powered Patient Transfer Standing Aids. The questionnaire is completed by references provided by offerors and submitted to Anthony.Zibolski@va.gov with the solicitation number in the email subject line.
The questionnaire requires references to rate offerors across seven performance areas using a five-point scale: Exceptional, Very Good, Satisfactory, Marginal, Unsatisfactory, or Not Applicable. The evaluation categories are Quality (service performance against contract standards), Schedule (timeliness of completion), Cost Control (applicable only to cost-reimbursable contracts), Management (integration and coordination of contract execution), Utilization of Small Business (compliance with small business requirements), and Regulatory Compliance (adherence to applicable regulations). References must also provide contract period of performance, dollar value, brief service description, and an overall recommendation indicating whether they would award the contract to the vendor again. The form requests the reference's name, title, phone number, email address, organization name, and details about any adverse actions such as Show Cause Orders, Stop Work Orders, or terminations issued against the offeror.
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Other files
| File | Type | Posted |
|---|---|---|
| ATTACHMENT G_Template for Industry Questions A0001.xlsx | XLSX spreadsheet | |
| ATTACHMENT F_Past Performance Questionnaire_36C10X26Q0110 A0001.docx | DOCX document | |
| ATTACHMENT D_Price Cost Schedule_36C10X26Q0110 A0001.xlsx | XLSX spreadsheet | |
| 36C10X26Q0110_2.docx | DOCX document | |
| ATTACHMENT E_Past Performance References_36C10X26Q0110.docx | DOCX document | |
| ATTACHMENT D_Price Cost Schedule_36C10X26Q0110.xlsx | XLSX spreadsheet | |
| ATTACHMENT B_Product Description_36C10X26Q0110.docx | DOCX document | |
| ATTACHMENT A_RFQ 36C10X26Q0110.pdf | ||
| 36C10X26Q0110.docx | DOCX document | |
| ATTACHMENT G_Template for Industry Questions.xlsx | XLSX spreadsheet | |
| ATTACHMENT C_Sales Reporting Tool_36C10X26Q0110.xlsx | XLSX spreadsheet |
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Text version
Attachment F Past Performance Questionnaire
SOLICITATION NO.: 36C10X26Q0110
DESCRIPTION: Non-Powered Patient Transfer Standing Aid
DEPARTMENT OF VETERANS AFFAIRS (VA)
STRATEGIC ACQUISITION CENTER (SAC)
PAST PERFORMANCE QUESTIONNAIRE
E-MAIL completed form to: Anthony.Zibolski@va.gov, ensuring that the email subject line includes “36C10X26R0009”
VA SAC is currently in the process of awarding a contract for the solicitation described above. The Offeror identified below has provided your organization’s name as a reference under the contract described below:
| Offeror Name: |
| (Offeror Insert Offeror’s Name Here) |
| Contract Number: |
| (Offeror Insert Applicable Contract Number Here) |
Please rate the Offeror in each of the categories on this questionnaire. See “Rating Guidelines” section for detailed description of categories and ratings. There is room for comments where you deem remarks would be helpful to our evaluation (see ‘Comment from Reference’ under “Offeror Evaluation.” Please note that the past performance evaluators for this solicitation may contact you for further details in making a fair assessment of this Offeror’s past performance. Thank you for your organization’s assistance in fairly evaluating Offeror proposals for this solicitation.
| Name of Reference: |
| (Reference Complete These Sections) |
Title of Reference:
Phone Number:
E-Mail Address:
Name of Organization:
Contract Period of Performance (Month/Day/Year Begin and End):
Total Contract Value (Base and All Option Years):
Options Exercised on Contract (Yes/No)?
Brief Description of Services/Commodity Provided by Offeror:
Show Cause Order Issued on Contract (Yes/No)?
Stop Work Order Issued on Contract (Yes/No)?
Termination for Convenience, Cause, or Default Issued on Contract (Yes/No)?
Instructions:
Please rate the vendor in each of the following areas. Note: there is room for comments where you deem remarks would be helpful to our evaluation.
· Exceptional: Performance that almost always exceeds the contract performance standard or requirement
· Very Good: Performance that meets and occasionally exceeds the contract performance standard or requirement
· Satisfactory: Performance that meets the minimum contract performance standard or requirement
· Marginal: Performance occasionally does not meet minimum contract performance standard or requirement
· Unsatisfactory: Performance clearly below the contract performance standard or requirement
· Not Applicable: N/A
| Performance Areas |
| Exceptional |
| Very Good |
| Satisfactory |
| Marginal |
| Unsatisfactory |
| N/A |
| 1. QUALITY | |||||
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Comments: Assess the achieved service performance relative to performance parameters required by the contract or order. |
| 2. SCHEDULE | |||||
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Comments: Assess the timeliness of the Contractor against the completion of the contract, task orders, milestones, delivery schedules, and administrative requirements (e.g., efforts that contribute to or affect the schedule variance). |
| 3. COST CONTROL (Not required for Fixed Price type contracts or orders) | |||||
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Comments: Assess the Contractor’s effectiveness in forecasting, managing, and controlling contract or order cost. |
| 4. MANAGEMENT | |||||
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Comments: Assess the integration and coordination of all activity needed to execute the contract or order, specifically the timeliness, completeness and quality of problem identification, corrective action plans, proposal submittals, the Contractor’s history of reasonable and cooperative behavior (to include timely identification of issues in controversy), customer satisfaction, timely award and management of subcontracts. |
| 5. UTILIZATION OF SMALL BUSINESS | |||||
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Comments: Assess compliance with all terms and conditions in the contract or order relating to Small Business participation (including FAR 52.219-8 Utilization of Small Businesses, and FAR 52.219-9 Small Business ☐Subcontracting Plan, when required). |
| 6. REGULATORY COMPLIANCE | |||||
| ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Comments: E.g failure to report in accordance with contract terms and conditions, late or nonpayment to subcontractors, trafficking violations, tax delinquency, defective cost or pricing data, terminations, suspension and debarments. Assess compliance with all terms and conditions in the contract/order relating to applicable regulations and codes, using the Evaluation Ratings Definitions. |
7. What was the contract period of performance (i.e., when were services provided)?
8. What was the dollar value of the contract performed by the vendor?
9. Provide a brief description of the services provided by the vendor for this contract.
| 10. Overall Recommendation |
| Would |
| Would Not |
| Signed |
| Given what I know today about the contractor’s ability to execute what he promised in his proposal, I _________________ award to him today given that I had a choice. | |
| ☐ | ☐ |
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