ATTACHMENT G - PAST PERFORMANCE QUESTIONAIRE - NX EQ LIFTS PATIENT TRANSFER FLOOR BASED BARIATRIC.docx
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- Solicitation number
- 36C10G26Q0017
About this file
This is a Past Performance Questionnaire template for the solicitation 36C10G26Q0017, issued by the Department of Veterans Affairs (VA) Strategic Acquisition Center for NX EQ Lifts patient transfer equipment (floor-based bariatric units). The questionnaire is designed to collect reference feedback from organizations that have previously worked with offerors bidding on this contract. References must submit completed questionnaires to Courtney Chattman at Courtney.Chattman@va.gov no later than February 20, 2026, at 16:30 CST.
The questionnaire requests that references provide ratings across four evaluation categories—Quality of Service, Cost Control, Timeliness of Performance, and Business Relations—using a three-point scale (Unsatisfactory, Satisfactory, or Excellent). Each category includes specific performance criteria, such as compliance with contract requirements, cost management effectiveness, milestone achievement, and responsiveness to inquiries. References must also indicate whether they would work with the offeror again and provide detailed comments supporting their ratings. Additional contract-related information required includes the reference organization's details, contract period of performance, total contract value, whether options were exercised, descriptions of services provided, and whether any show cause, stop work, or termination orders were issued. This template allows offerors to submit a maximum of five references from the past three years to support their proposal evaluation.
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36C10G26Q0017 Attachment G Past Performance Questionnaire
SOLICITATION NO.: 36C10G26Q0017
DESCRIPTION: NX EQ Lifts: Patient Transfer: Floor Based: Bariatric Brand Name or Equal
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: Courtney Chattman E-MAIL: Courtney.Chattman@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 Courtney.Chattman@va.gov no later than February 20, 2026, at 16:30 CST.
| 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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