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 for the VA's procurement of NX EQ Image-Guided Surgical Navigation Systems under solicitation 36C10X27R0004. The questionnaire is designed to be completed by references provided by offerors and submitted to the Department of Veterans Affairs Enterprise Procurement Office (EPO) by November 5, 2026, at 12:00 p.m. Eastern. References must evaluate offerors across four primary performance categories—Quality of Service, Cost Control, Timeliness of Performance, and Business Relations—using a three-tier rating scale: Unsatisfactory (1), Satisfactory (2), and Excellent (3), with space for detailed comments in each category. The questionnaire also includes a final section requesting an overall satisfaction rating regarding the reference's willingness to work with the offeror again.
The form requires references to provide organizational information, contract details including period of performance and total contract value, and disclose whether options were exercised or any adverse actions such as show cause orders, stop work orders, or terminations were issued. The evaluation criteria assess compliance with contract requirements, cost management effectiveness, adherence to schedules and milestones, invoice accuracy, personnel quality, and responsiveness to inquiries and technical direction. Completed questionnaires should be returned to Alanna Wilson and Sara Vickroy at the VA EPO. This template is a component of the broader solicitation for NX EQ Image-Guided Surgical Navigation Systems, which is set aside for Service-Disabled Veteran-Owned Small Businesses, with delivery on an FOB Destination basis to locations specified in individual orders.
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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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