ATTACHMENT G - PAST PERFORMANCE QUESTIONAIRE - NX EQ PHYSIOLOGIC VITAL SIGNS MONITOR.docx

Attachment G Past Performance Questionnaire

SOLICITATION NO.: 36C10G23R0014

DESCRIPTION: NX EQ Physiologic Vital Signs Monitors – Welch Allyn 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: Ninatile Bacote E-MAIL: Ninatile.Bacote@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)

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 Ninatile.Bacote@va.gov by June 23, 2023, at 11:59 PM EST._

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:

Offeror Evaluation:

Comment from Reference: _______________________