ATTACHMENT F - PAST PERFORMANCE QUESTIONNAIRE_NX EQ Image-Guided Surgical Navigation System.docx
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- Solicitation number
- 36C10X27R0004
About this file
This is a Past Performance Questionnaire template used by the Department of Veterans Affairs Enterprise Procurement Office (VA EPO) to evaluate offerors competing for solicitation 36C10X27R0004, a contract for NX EQ Image-Guided Surgical Navigation Systems. The questionnaire is completed by references provided by offerors and must be submitted to Alanna Wilson (Alanna.Wilson@va.gov) and Sara Vickroy (Sara.Vickroy@va.gov) by November 5, 2026, at 12:00 p.m. Eastern Time.
The questionnaire requests references to rate offerors across four evaluation categories: Quality of Service, Cost Control, Timeliness of Performance, and Business Relations, using a three-point rating scale (1=Unsatisfactory, 2=Satisfactory, 3=Excellent). References must provide detailed descriptions of the offeror's performance in each category, including compliance with contract requirements, cost management effectiveness, milestone achievement, and responsiveness to contract administration. The template also includes a yes/no question regarding overall satisfaction and whether the reference would engage the offeror for future work. References are requested to provide basic contract information including the contract number, period of performance, total contract value, and whether options were exercised, stop work orders were issued, or terminations occurred. The VA EPO evaluators may contact references for additional clarification during the proposal evaluation process.
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Attachment F Past Performance Questionnaire
SOLICITATION NO.: 36C10X27R0004
DESCRIPTION: NX EQ Image-Guided Surgical Navigation System
DEPARTMENT OF VETERANS AFFAIRS (VA)
ENTERPRISE PROCUREMENT OFFICE (EPO)
PAST PERFORMANCE QUESTIONNAIRE
TO: Alanna Wilson and Sara Vickroy E-MAIL: Alanna.Wilson@va.gov and Sara.Vickroy@va.gov
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.
Please E-mail Questionnaire to Alanna.Wilson@va.gov and Sara.Vickroy@va.gov by November 5, 2026, at 12:00pm Eastern.
| 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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