Attachment K - Past Performance Questionnaire - 0122.docx
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- Solicitation number
- 36C78626Q0122
About this file
This is a Past Performance Questionnaire template that offerors must use to collect reference information from evaluators regarding their past performance on previous contracts. Offerors are required to identify an evaluator for each past performance reference and directly request that individual complete and return the survey to Weston.Worsham@va.gov and Patara.Mcdonald@va.gov no later than October 19, 2026 at 10:00 a.m. CST. The questionnaire requests information about services provided, length of service, and evaluator assessment across fifteen rating criteria using a five-point scale (Outstanding, Above Average, Satisfactory, Marginal, Unacceptable). Key evaluation areas include compliance with contract requirements, timeliness, labor and safety standards compliance, contract management effectiveness, personnel practices, work quality, flexibility, reliability, technical responsiveness, and customer satisfaction.
The questionnaire also requires yes/no responses regarding cure notices, show cause letters, or termination actions; future contract award likelihood; invoice accuracy; and professionalism. Evaluators must provide additional remarks if ratings are Marginal or Unacceptable. The survey is designated Source Selection Sensitive under FAR 2.101 and 3.104, protecting the confidentiality of evaluator identities. Offerors must include a copy of each completed past performance questionnaire or provide equivalent information with their quote submission for the L099--Onsite Inscription Services for Jefferson Barracks National Cemetery contract opportunity (Solicitation 36C78626Q0122) with the Department of Veterans Affairs National Cemetery Administration.
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Attachment K – Past Performance Questionnaire Past Performance Information
OFFEROR INSTRUCTIONS: A separate record must be completed for each Past Performance Information and Survey. Offeror must directly send to the evaluator, requesting they complete and return as indicated on the attached Past Performance Survey, no later than, 19 October 2026 at 10:00 a.m. CST to Weston.Worsham@va.gov and Patara.Mcdonald@va.gov. Further, Offeror must either include a copy of each requested Past Performance Information page or provide the same information on a separate document with quote submission.
Name of Offeror being evaluated:
Address of Offeror:
Contract Details (i.e. Contract #/ Delivery or Task Order #, Title, Location, etc)
Evaluator’s Full Name:
Evaluator’s Position held or function in relation to project:
Evaluator’s Company/Organization Name, Address and Phone number:
Evaluator’s email address:
Please complete and return to: Weston.Worsham@va.gov and Patara.Mcdonald@va.gov No Later Than: 19 October 2026, at 10:00 a.m. CST
Past Performance Survey
Reference Instructions: The Department of Veterans Affairs is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation (FAR) 15.506 prohibits the release of the names of the individuals providing reference information about the Offeror’s past performance. Survey should be completed by the evaluator and returned to Weston.Worsham@va.gov, no later than the above date.
Please evaluate the Past Performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, provide additional information in the appropriate block or in the remarks section of this form.
O = Outstanding = Performance greatly exceeded contract requirements
A = Above Average = Performance exceeded contract requirements
S = Satisfactory = Performance met contract requirements
M = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory.
U = Unacceptable = Performance was poor and/or did not satisfy contract requirements
NOTE: Do not use a color marking pen to circle the response. Best to use a ball point pen (Black or Blue) or electronic means to circle your response .
Describe the services provided to your company/organization?
Length of the Service (Provide dates):
| Rate the following questions if the company provided on-site inscription services or similar services. Provide information/comments in the Remarks Section below. |
| Circle One |
Q1. To what extent did the contractor comply with contract requirements?
O A S M U
Q2. How timely was the contractor’s performance?
O A S M U
Q3. How well did the contractor comply with the labor and safety standards?
O A S M U
Q4. Rate the effectiveness of the contractor’s management of the contract?
O A S M U
Q5. Rate the contractor’s personnel management practices.
O A S M U
Q6. Quality Control: Rate the overall quality of contractor’s work.
O A S M U
Q8. What extent was contractor flexible in responding to changing needs?
O A S M U
Q9. To what extent was the contractor reliable?
O A S M U
Q10. To what extent was the Contractor responsive to technical directions?
O A S M U
Q11. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, explain on the following page.
Yes No
Q12. Would you award another contract to this contractor? If no, explain on the following page.
Yes No
Q13. Was the customer satisfied with the service provided? If no, explain on the following page.
Yes No
Q14. To what extent did contractor notify you of problems of potential issues?
O A S M U
| Q15. Did the Contractor submit accurate invoices during the performance period? |
| Yes No |
| Q16. Was the contractor professional and courteous in its interaction with you? |
| Yes No |
| Q17. Did the contractor respond promptly to requests? |
| Yes No |
| Q18. Did the contractor meet all expectations under the contract? |
| Yes No |
Past Performance Survey – Remarks Section
Evaluator’s Additional Remarks regarding services:
Signature of Evaluator: Date of Evaluation:
Print Name of Evaluator:
Please email scanned copy directly to Weston.Worsham@va.gov and Patara.Mcdonald@va.gov.
DO NOT return survey to the company you are evaluating.
Source Selection Sensitive IAW FAR 2.101 and 3.104
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