ATTACHMENT F - PAST PERFORMANCE QUESTIONNAIRE NX EQ Ophthalmic Perimeters.pdf

Attachment F Past Performance Questionnaire

SOLICITATION NO.: 36C10G25R0049

DESCRIPTION: NX EQ Ophthalmic Perimeters– Zeiss® Brand Name or Equal

Offerors: Please Send to Each Reference Cited in Submitted Proposal (Maximum of Five References from Past Three Years)

DEPARTMENT OF VETERANS AFFAIRS (VA)

STRATEGIC ACQUISITION CENTER (SAC)

PAST PERFORMANCE QUESTIONNAIRE

TO: Alex Beck/ Anthony Zibolski E-MAIL: Alex.Beck1@va.gov/ Anthony.Zibolski@va.gov

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: (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 Alex.Beck1@va.gov and Anthony.Zibolski@va,gov by August 22 21, 2025, at 11:59 PM EST.

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)?

mailto:Alex.Beck1@va.gov

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:

Comment from Reference: _______________________

Timeliness of Performance

Has met milestones, is reliable, is responsive to technical direction, and has completed milestones on-time or ahead of schedule:

Comment from Reference: _______________________

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:

Comment from Reference: _______________________

YES NO Overall Satisfaction

Would you (reference) choose to work with this offeror again?

Comment from Reference: _______________________