Attachment V.- Past Performance Questionnaire - PPQ.pdf

Department of Veterans Affairs VISN Healthcare System

PAST PERFORMANCE QUESTIONNAIRE FOR VISN

INSTRUCTIONS TO OFFEROR

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.

Company Name Street Address

Point of Contact

(POC)

City

POC Phone Number

State

Reference Project Title

Zip Code

Contract Period of Performance (start to finish):

Email

Contract Number Contract Dollar Value

Description of Work Role of Contractor on This Project (check appropriate box)

Prime Contractor Sub-contractor Key Personnel

INSTRUCTIONS TO REFERENCE CONTACT

The contractor named above is submitting a proposal for a United States Department of Veterans Affairs contract and has sent this form to you as a past performance reference contact. Please complete the following pages in full (all areas shaded in light yellow, below). Once completed, please send the form directly to the email below:

Email address: jean.paul@va.gov

If you have any questions, please contact the Contract Specialist:

SOURCE SELECTION SENSITIVE WHEN COMPLETED*****NOT TO BE RELEASED

OUTSIDE GOVERNMENT CHANNELS*****RETURN THIS PAGE WITH

QUESTIONAIRE.

RESPONDENT INFORMATION [completed by Reference Contact]

Company Name Street Address

POC Name City

Phone Number State

Email Zip Code

PERFORMANCE INFORMATION: Choose the number on the scale of 0 (Neutral) to 5 (Exceptional) that most accurately describes the contractor�s performance or situation. PLEASE PROVIDE AN EXPLANATION FOR THE OVERALL RATING in the Remarks section, below.

0 1 2 3 4 5

NEUTRAL

UNACCEP

TABLE

MARGINA

L

ACCEPTA

BLE

VERY

GOOD

OUTSTAN

DING

No record of past performance, or not applicable or the record is inconclusive.

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 most 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 exceeded all contract requirements.

There were no problems.

Jean M. Paul at jean.paul@va.gov

QUALITY � MANAGEMENT & WORKMANSHIP

0 1 2 3 4 5

1.

How well did the Offeror utilize quality control process that ensured conformance to scope and quality requirements?

2.

Demonstrated ability to hire, maintain, and replace, if necessary, qualified construction personnel during the contract period.

3.

Provided and followed approved quality control plan and/or inspection procedures to meet contract requirements.

4.

Corrected deficiencies in timely manner and pursuant to their quality control procedures.

5.

Submittals clearly identified the proposed item in accordance with (IAW) the specifications and drawings.

6. Suggested alternative approaches to problems.

TIMELINESS AND ADHERENCE TO SCHEDULE

0 1 2 3 4 5

7.

Contractor provided timely notices of possible delays/schedule revisions.

REMARKS:

8.

Timeliness in submitting submittals and reports and responding to agency inquiries, RFP's, etc.

REMARKS:

9. Developed realistic and met approved progress schedules.

BUSINESS PRACTICES/CUSTOMER RELATIONSHIP AND ABILITY TO

PERFORM

0 1 2 3 4 5

10.

Displayed initiative to solve problems.

REMARKS:

11.

How well did the contractor work independent of Government guidance, oversight, and assistance?

REMARKS:

12.

Subcontractors / tradesmen were adequately managed and coordinated. Explain any subcontracting issues (positive or negative) that impacted the performance of your contract(s).

REMARKS:

13.

Contractor independently coordinated with state and city permitting/environmental agencies, public safety departments, and public utility companies.

14.

For contract changes, contractor provided timely and realistic change order proposals.

COMPLIANCE & SAFETY

0 1 2 3 4 5

15.

Reports (i.e., daily, test, logs)/records were submitted completely and accurately to satisfy the requirement.

16.

Applicable to Federal Contracts �Contractor complied with applicable Federal Laws and Regulations such as Construction Wage Rate Requirements � timely payrolls and compliance; Drug-Free Workplace; Environmental Regulations and Use of Recovered Materials; Executive Order 13101 Greening the Government.

17.

Contractor�s safety program was in compliance with federal regulations. Contractor implemented and followed their safety plan and ran a safe jobsite.

INFECTION CONTROL

0 1 2 3 4 5

18.

Contractor had an Infection Control Process in place and complied with agency Infection Control Requirements.

REMARKS:

OVERALL CUSTOMER SATISFACTION

0 1 2 3 4 5

19.

Demonstrated reasonableness in modifications cost proposal.

20.

Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in the remarks section.

YES NO

21.

Would you award another contract to this contractor? If not, please explain in the remarks section.

YES NO

OVERALL PERFORMANCE RATING:

REMARKS (Please use as much space as is needed � the box will expand as you type).

I hereby certify that the information that I have reported above is accurate to the best of my knowledge.

Printed Name E-mail address

Business Title Signature Date