Attachment K - Past Performance Questionnaire.docx
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- Solicitation number
- 36C78626Q0125
About this file
This is a Past Performance Questionnaire attachment for the Department of Veterans Affairs' solicitation for on-site inscription services at Fort Snelling National Cemetery (Solicitation Number 36C78626Q0125). The questionnaire serves as a template for evaluators to assess offerors' past performance on relevant contracts. Offerors must directly solicit completed questionnaires from references and submit them to the evaluation team at Weston.Worsham@va.gov and Patara.Mcdonald@va.gov no later than October 20, 2026 at 1:00 p.m. CST. Alternatively, offerors may include copies of completed Past Performance Information pages with their quote submission.
The questionnaire requires evaluators to rate contractor performance across 18 evaluation criteria using a standardized five-point scale: Outstanding (O), Above Average (A), Satisfactory (S), Marginal (M), and Unacceptable (U). Key rating areas include contract compliance, timeliness, labor and safety standards adherence, management effectiveness, personnel practices, quality control, flexibility, reliability, responsiveness to technical direction, invoicing accuracy, and customer satisfaction. The form also includes yes/no questions regarding cure notices, termination actions, contract award willingness, customer satisfaction, and contractor professionalism. Evaluators must provide explanatory remarks if ratings of Marginal or Unacceptable are assigned, and completed questionnaires are designated as Source Selection Sensitive information subject to FAR confidentiality protections.
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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, 20 October 2026 at 1:00 p.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: 20 October 2026, at 1:00 p.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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