ATTACHMENT F_PAST PERFORMANCE QUESTIONNAIRE_NX EQ AB Scan.docx
DOCX document 34 KB Posted
- Solicitation number
- 36C10X26R0055
About this file
This is a Past Performance Questionnaire template for evaluating offerors responding to VA solicitation 36C10G26R0055 for NX EQ Scanning Systems Ultrasonic Ophthalmic AB Scan equipment. The questionnaire is designed to be completed by references provided by offerors and submitted directly to the VA Enterprise Procurement Office at kimberly.lemieux@va.gov with the solicitation number in the email subject line. References are limited to a maximum of three from the past three years.
The questionnaire evaluates offerors across four primary rating categories—Quality of Service, Cost Control, Timeliness of Performance, and Business Relations—each scored on a three-point scale: Unsatisfactory (1), Satisfactory (2), or Excellent (3). Each category includes specific evaluation criteria and space for detailed comments from the reference. The form also requests background information including the reference's name, title, organization, phone number, email address, contract period of performance, total contract value, and whether options were exercised. References must disclose whether Show Cause Orders, Stop Work Orders, or Termination notices were issued on the referenced contract. The questionnaire concludes with an overall satisfaction question asking whether the reference would choose to work with the offeror again.
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Other files
| File | Type | Posted |
|---|---|---|
| ATTACHMENT C_SALES REPORTING TOOL_NX EQ AB Scan.xlsx | XLSX spreadsheet | |
| ATTACHMENT B_Product Description NX EQ AB Scan.docx | DOCX document | |
| ATTACHMENT E_PAST PERFORMANCE REFERENCES_NX EQ AB Scan.docx | DOCX document | |
| 36C10X26R0055 - RFP.docx | DOCX document | |
| ATTACHMENT D_Template for Industry Questions_NX EQ AB Scan.xlsx | XLSX spreadsheet | |
| ATTACHMENT A_PRICE COST SCHEDULE_NX EQ AB Scan.xlsx | XLSX spreadsheet | |
| 36C10X26R0055_1.docx | DOCX document |
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Text version
SOLICITATION NO.: 36C10G26R0055
DESCRIPTION: NX EQ Scanning Systems Ultrasonic Ophthalmic AB Scan
Attachment F Past Performance Questionnaire Offerors: Please Send to Each Reference Cited in Submitted Proposal (Maximum of 3 References from Past Three Years)
DEPARTMENT OF VETERANS AFFAIRS (VA)
ENTERPRISE PROCUREMENT OFFICE (EPO)
PAST PERFORMANCE QUESTIONNAIRE
E-MAIL completed form to: kimberly.lemieux@va.gov, ensuring that the email subject line includes “36C10G26R0055”
VA EPO 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: |
| (Insert Offeror’s Name Here) |
| Contract Number: |
| (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)?
Rating Guidelines:
| Rating |
| Quality of Service |
| Cost Control |
| Timeliness of Performance |
| Business Relations |
| 1: Unsatisfactory |
| Offeror is not in compliance and has jeopardized achievement of contract objectives |
| Offeror is unable to manage costs effectively |
| Offeror delays have jeopardized performance |
| Responses to inquiries and issues are not effective |
| 2: Satisfactory |
| Minor inefficiencies and errors have been identified |
| Offeror is usually effective in managing costs |
| Offeror is usually effective in meeting milestones and delivery schedule |
| Responses to inquiries and issues is usually effective |
| 3: Excellent |
| Offeror is in compliance with contract requirements and delivers quality services |
| Offeror is effective in managing costs and submits proper invoices |
| Offeror is effective in meeting and exceeding milestones and delivery schedule |
| Responses to inquiries have been effective and/or exceeded expectations and established deadlines |
Offeror Evaluation:
| Rating (List Number Based on Rating Guidelines Above) |
| Category |
| Description |
| Quality of Service |
| In compliance with contract requirements, submits accurate reports/deliverables, has effective personnel, and has achieved/maintained technical excellence: |
Comment from Reference: _______________________
| Cost Control |
| Has achieved efficiencies in costs, managed costs effectively, and has submitted timely/accurate invoices with supporting documentation: |
| Timeliness of Performance |
| Has met milestones, is reliable, is responsive to technical direction, and has completed milestones on-time or ahead of schedule: |
| Business Relations |
| Has maintained effective management of contract, has exhibited reasonable/cooperative behavior, is responsive to contract requirements, is responsive to inquiries/issues, and is proactive about resolving problems: |
| |_| YES |_| NO |
| Overall Satisfaction |
| Would you (reference) choose to work with this Offeror again? |
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