Attachment H Past Performance Questionnaire - 3 Pages.docx
DOCX document 26 KB Posted
- Solicitation number
- 36C26323R0023
About this file
This document contains a past performance questionnaire template for a federal contract opportunity to renovate a private patient bed ward for the Department of Veterans Affairs. The contractor must provide the past performance questionnaire to references for completed projects. References will evaluate the contractor's performance on a scale of 1 to 5 in areas such as management, quality control, scheduling, responsiveness to changes, and overall performance. References must return the completed questionnaire to the contracting specialist by April 21, 2023. The opportunity is solicitation number 36C26323R0023 to renovate a private patient bed ward for $618,222 at a Department of Veterans Affairs medical center.
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Text version
PAST PERFORMANCE QUESTIONNAIRE
36C26323R0023, Renovate for a Private Patient Bed Ward (3D)- PN 618-22-102
INSTRUCTIONS TO CONTRACTOR
Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and submit it according to the instructions, below.
INSTRUCTIONS TO REFERENCE CONTACT
The contractor named below is submitting an offer for a United States Department of Veterans Affairs contract requirement, and has sent this form to you, in your role as a past performance reference contact. Please complete this form in full (all areas shaded in light yellow, below). Once completed, please send the form directly to the Contracting Specialist via email at Angela.Frost2@va.gov . Please return the completed form by April 21, 2023, at 10:00 am CT.
GENERAL INFORMATION [completed by Contractor]
Contractor Company Name
Street Address
Contractor Point of Contact Name
City
Point of Contact Phone Number
State
Reference Project Title
Zip Code
Contract Period of Performance (start to finish):
Contract Number
Contract Dollar Value
Description of Work
| Role of Contractor on This Project (check appropriate box) |
| ☐ Prime Contractor ☐ Sub-contractor ☐ Key Personnel |
RESPONDENT INFORMATION [completed by Reference Contact]
Company Name
Street Address
POC Name
City
Phone Number
State
Fax Number
Zip Code
PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 5 that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 1 OR 2 in the Remarks section, below (text box will expand to whatever extent is necessary).
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| UNSATISFACTORY |
| MARGINAL |
| SATISFACTORY |
| VERY GOOD |
| EXCEPTIONAL |
| Performance did not meet most contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective. |
| Performance did not meet some contractual requirements. There were problems, some of a serious nature, for which corrective action was only marginally effective. |
| Performance met contractual requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory. |
| Performance met all contract requirements and exceeded some to the government’s benefit. There were a few minor problems, which the contractor resolved in a timely, effective manner. |
| Performance met all contract requirements and exceeded many to the government’s benefit. Problems, if any, were negligible and were resolved in a timely, highly effective manner. |
| The Contractor … |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| 1. |
| Provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements. |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| 2. |
| Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period. |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| 3. |
| Delegated authority to project managers and supervisors commensurate with contract requirements. |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| 4. |
| Home office participated in solving significant local problems. |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| 5. |
| Followed approved quality control plan. |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| 6. |
| Provided effective quality control and/or inspection procedures to meet contract requirements. |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| 7. |
| Corrected deficiencies in timely manner and pursuant to their quality control procedures. |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| 8. |
| Provided timely resolution of contract discrepancies |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| 9. |
| Identified problems as they occurred. |
| ☐ |
| ☐ |
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| ☐ |
| ☐ |
| 10. |
| Suggested alternative approaches to problems. |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| ☐ |
| 11. |
| Displayed initiative to solve problems. |
| ☐ |
| ☐ |
| ☐ |
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| ☐ |
| 12. |
| Developed realistic progress schedules. |
| ☐ |
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| ☐ |
| 13. |
| Met established project schedules. |
| ☐ |
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| ☐ |
| 14. |
| Provided timely resolution of warranty defects. |
| ☐ |
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| 15. |
| Was responsive to contract changes. |
| ☐ |
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| 16. |
| Provided adequate project supervision. |
| ☐ |
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| 17. |
| Obtained consent of surety for increases in bonding as work-in-progress increased. |
| ☐ |
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| 18. |
| Paid subcontractors/suppliers in a timely manner. |
| ☐ |
| ☐ |
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| ☐ |
| 19. |
| Provided accurate and complete line item cost proposals including all aspects of work required for each task. |
| ☐ |
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| 20. |
| Cooperated with Government personnel after award. |
| ☐ |
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| 21. |
| How would you rate the contractor's overall performance? |
| ☐ |
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| ☐ |
| ☐ |
| 22. |
| Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.” |
| ☐ |
YES
NO
| 23 |
| Would you award another contract to this contractor? If not, please explain in “remarks.” |
| ☐ |
YES
NO
| 24 |
| To the best of your knowledge, is the contractor rated in CPARS? |
| ☐ |
YES
NO
REMARKS (Please use as much space as is needed – the box will expand as you type).
Name of Person Completing Form Signature
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