ATTACHMENT G - PAST PERFORMANCE QUESTIONAIRE - NX EQ EEG SYSTEMS.docx

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6515--NX EQ EEG Systems
Solicitation number
36C10X26R0032
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This is a Past Performance Questionnaire template for the Department of Veterans Affairs Strategic Acquisition Center to evaluate offerors responding to solicitation 36C10X26R0032 for NX EQ EEG Systems (Electroencephalography Systems). The questionnaire is to be completed by references provided by offerors, with a maximum of five references from the past three years. Completed questionnaires must be emailed to Levi Russin at Levi.Russin@va.gov no later than July 29, 2026, at 12:00 PM ET.

References are required to provide ratings and comments across four evaluation categories: Quality of Service, Cost Control, Timeliness of Performance, and Business Relations. Each category uses a three-point rating scale (1=Unsatisfactory, 2=Satisfactory, 3=Excellent) with detailed criteria for each rating level. References must also indicate whether they would choose to work with the offeror again. The questionnaire collects information on contract details including contract number, period of performance, total contract value, options exercised, and service descriptions, as well as whether any show cause orders, stop work orders, or terminations were issued during contract performance.

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Other files

File Type Posted
ATTACHMENT H - RFQ QUESTIONS - NX EQ EEG SYSTEMS.xlsx XLSX spreadsheet
ATTACHMENT E - QUARTERLY SALES REPORT - NX EQ EEG SYSTEMS.xlsx XLSX spreadsheet
ATTACHMENT D - SOLICITATION PROVISIONS - NX EQ EEG SYSTEMS.docx DOCX document
ATTACHMENT C - CONTRACT CLAUSES - NX EQ EEG SYSTEMS.docx DOCX document
36C10X26R0032.docx DOCX document
ATTACHMENT F - PAST PERFORMANCE REFERENCES - NX EQ EEG SYSTEMS.pdf PDF
ATTACHMENT B - CONTRACT ADMINISTRATION - NX EQ EEG SYSTEMS.docx DOCX document
ATTACHMENT A - PRICE COST SCHEDULE - NX EQ EEG SYSTEMS.xlsx XLSX spreadsheet

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Attachment G Past Performance Questionnaire

SOLICITATION NO.: 36C10X26R0032

DESCRIPTION: NX EQ EEG SYSTEMS

Offerors: Please send each reference cited in submitted quote (maximum of five references from past three (3) years)

DEPARTMENT OF VETERANS AFFAIRS (VA)

STRATEGIC ACQUISITION CENTER (SAC)

PAST PERFORMANCE QUESTIONNAIRE

TO: Levi Russin E-MAIL: Levi.Russin@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 Levi.Russin@va.gov no later than July 29, 2026, at 12:00 PM ET.

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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