Attachment F_Past Performance Questionnaire_NX EQ Irrigation Systems for Endoscopy.docx
DOCX document 50 KB Posted
- Solicitation number
- 36C10X26R0030
About this file
This is a Past Performance Questionnaire template for the Department of Veterans Affairs (VA) Enterprise Procurement Office evaluating offerors for Solicitation No. 36C10X26R0030, which concerns the procurement of NX EQ Irrigation Systems for Endoscopy. The questionnaire is designed to be completed by past performance references cited by offerors in their proposals, with a maximum of three references from the past three years. Completed forms must be emailed to Kimberly.LeMiuex@va.gov and Michael.Andrews6@va.gov with the solicitation number in the subject line.
The questionnaire requires references to provide detailed evaluation information across seven performance categories: Quality, Schedule, Cost Control, Management, Utilization of Small Business, and Regulatory Compliance, using a five-point rating scale (Exceptional, Very Good, Satisfactory, Marginal, or Unsatisfactory) with space for supporting comments. References must also supply contract-specific details including the contract period, total contract value, whether options were exercised, and whether any adverse actions such as show cause orders, stop work orders, or terminations were issued. The questionnaire concludes with an overall recommendation section asking whether the reference would award the contract to the vendor today if given the choice. This template does not contain specific contract requirements, pricing, or solicitation timelines but rather serves as an evaluation mechanism for past performance assessment.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C10X26R0030 0001.docx | DOCX document | |
| Attachment H_Certification of Recall or Safety Issue_NX EQ Irrigation Systems for Endoscopy.docx | DOCX document | |
| Attachment E_Past Performance References_NX EQ Irrigation Systems for Endoscopy.docx | DOCX document | |
| Attachment D_Price Cost Schedule_NX EQ Irrigation Systems for Endoscopy.xlsx | XLSX spreadsheet | |
| Attachment A_RFP 36C10X26R0030_NX EQ Irrigation Systems for Endoscopy.docx | DOCX document | |
| Attachment G_Template for Industry Questions_NX EQ Irrigation Systems for Endoscopy.xlsx | XLSX spreadsheet | |
| Attachment B_Product Description_NX EQ Irrigation Systems for Endoscopy.docx | DOCX document | |
| 36C10X26R0030_1.docx | DOCX document | |
| Attachment C_Sales Reporting Tool_NX EQ Irrigation Systems for Endoscopy.xlsx | XLSX spreadsheet |
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Text version
Attachment F Past Performance Questionnaire
SOLICITATION NO.: 36C10X26R0030
DESCRIPTION: Irrigation Systems for Endoscopy
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.LeMiuex@va.gov and Michael.Andrews6@va.gov, ensuring that the email subject line includes “36C10X26R0030”
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: |
| (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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