ATTACHMENT F - PAST PERFORMANCE QUESTIONNAIRE -NX EQ Scanning System Ultras.docx
DOCX document 27 KB Posted
- Attached to
- NX EQ Scanning System Ultrasonic Endoscopic
- Solicitation number
- 36C10G26R0005
About this file
The document is a Past Performance Questionnaire for a Department of Veterans Affairs (VA) Strategic Acquisition Center solicitation (36C10G26R0005) for a Scanning System Ultrasonic Endoscopic procurement. The solicitation seeks a national single requirements contract for medical imaging equipment, specifically an NX EQ Scanning System (FujiFilm Arietta 850 or equivalent) to be used by VA medical centers. The contract has a base 12-month period with four additional 12-month option periods.
The questionnaire is designed to collect reference feedback on potential contractors, evaluating their performance across four key categories: quality of service, cost control, timeliness of performance, and business relations. References are asked to provide ratings from 1 (unsatisfactory) to 3 (excellent) and are requested to complete and submit the questionnaire by 12/18/2025 at 11:59am EST to Cyia Jones via email. The medical device is used for diagnosing and staging cancer, performing biopsies, draining cysts, and delivering targeted medication, with the VA seeking a contractor who can demonstrate comprehensive capability to meet all solicitation requirements.
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Attachment F Past Performance Questionnaire
SOLICITATION NO.: 36C10G26R0005
DESCRIPTION: NX EQ Scanning System Ultrasonic Endoscopic – FujiFilm® Arietta 850 or equal Scanning System Ultrasonic Endoscopic
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: Cyia Jones E-MAIL: Cyiamaudia.Jones@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 Cyiamaudia.Jones@va.gov by 12/18/2025, at 11:59am 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)?
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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