ATTACHMENT F_PAST PERFORMANCE QUESTIONNAIRE_NX EQ Laparoscopic Insufflators.docx
DOCX document 41 KB Posted
- Solicitation number
- 36C10X26R0009
About this file
This is a past performance questionnaire template designed for the Department of Veterans Affairs Strategic Acquisition Center to evaluate offerors' performance on prior contracts related to Laparoscopic Insufflators under Solicitation No. 36C10X26R0009. The questionnaire is to be completed by references cited in offeror proposals (maximum of three references from the past three years) and submitted via email to Carey.Kauzlarich@va.gov and Anthony.Zibolski@va.gov with the solicitation number in the subject line.
The questionnaire requires references to rate offerors across seven performance categories: Quality, Schedule, Cost Control (not required for fixed-price contracts), Management, Utilization of Small Business, and Regulatory Compliance. Each category uses a five-point rating scale ranging from Exceptional to Unsatisfactory, with space for comments on each evaluation criterion. References must also provide basic contract information including contract number, period of performance, total contract value, and a brief description of services provided. The form concludes with an overall recommendation section requiring the reference to indicate whether they would award the contract to the offeror based on their demonstrated ability to execute their proposal. This questionnaire is a standard past performance evaluation tool used to assess contractor capability and compliance history for the VA's acquisition of NX EQ Laparoscopic Insufflators, which is a service-disabled veteran-owned small business set-aside.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| ATTACHMENT G_Template for Industry Questions_A0001.xlsx | XLSX spreadsheet | |
| ATTACHMENT H_CERTIFICATION OF RECALL OR SAFETY ISSUES.docx | DOCX document | |
| ATTACHMENT A_RFP 36C10X26R0009 A0001_NX EQ Laparoscopic Insufflators.pdf | ||
| 36C10X26R0009_2.docx | DOCX document | |
| ATTACHMENT B PD NX EQ Laparoscopic Insufflators.pdf | ||
| 36C10X26R0009.docx | DOCX document | |
| ATTACHMENT D_PRICE COST SCHEDULE_NX EQ Laparoscopic Insufflators.xlsx | XLSX spreadsheet | |
| ATTACHMENT A_RFP 36C10X26R0009_NX EQ Laparoscopic Insufflators.pdf | ||
| ATTACHMENT G_Template for Industry Questions.xlsx | XLSX spreadsheet | |
| ATTACHMENT E_PAST PERFORMANCE REFERENCES_NX EQ Laparoscopic Insufflators.docx | DOCX document | |
| ATTACHMENT C_SALES REPORTING TOOL_NX EQ Laparoscopic Insufflators.xlsx | XLSX spreadsheet |
Show all 11
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Attachment F Past Performance Questionnaire
SOLICITATION NO.: 36C10X26R0009
DESCRIPTION: Laparoscopic Insufflators
Offerors: Please Send to Each Reference Cited in Submitted Proposal (Maximum of 3 References from Past Three Years)
DEPARTMENT OF VETERANS AFFAIRS (VA)
STRATEGIC ACQUISITION CENTER (SAC)
PAST PERFORMANCE QUESTIONNAIRE
E-MAIL completed form to: Carey.Kauzlarich@va.gov and 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. | |
| ☐ | ☐ |
File details come from the government source that posted it. Updated .