D.1 Past Performance Questionnaire.docx

D.1 PAST PERFORMANCE QUESTIONAIRE

We are currently in the process of preparing our offer for the Hampton, VA Network Contracting Office 6 (NCO 6), Solicitation Number 36C24623Q0900. As part of our offer, we have listed you as a reference on our performance for this type of service with your agency under the previous/current contract listed below. Your input on our performance is therefore requested.

Please complete this Questionnaire and e-mail or fax to Contracting Officer, David E. Smith e-mail David.Smith78@va.gov

Questionnaire is due to David E. Smith, no later than 8:00 AM EST on 4 August 2023. Questionnaire must be emailed directly to the CO from a corporate email account.

If you will not be available on 4 August 2023 for verification of this past performance evaluation, please indicate alternate POC for the contacting officer to contact.

Alternate POC name:

Alternate POC phone number:

Alternate POC e-mail address:

******************************************************************************* NAME OF OFFEROR: _________________________________ Phone: ________________

E-Mail: _____________________________________________

I. Current or Historical Contract

Information CONTRACT REFERENCED:

1. Contract or Identifying Number:

2. Contract Value:

3. Period of Performance:

4. Brief description of items provided:

36C24623Q0900

5. Name of Person Completing Questionnaire:

Agency/Company:

Title: Phone:

E-mail:

II. EVALUATION. Please rate the Contractor utilizing the guide below. Explanatory narratives for as many responses as possible would be appreciated. These narratives need not be lengthy, just detailed. Attach additional pages if more space is needed.

Evaluation Definitions – The following definitions should be used in the assessment of Contractor performance.

EXCEPTIONAL

Performance EXCEEDS MOST contractual requirements. The performance of areas being assessed was accomplished with few minor issues or concerns.

VERY GOOD

Performance EXCEEDS SOME contractual requirements. The performance of areas being assessed was accomplished with few minor issues or concerns, for which the Contractor’s corrective actions were highly effective.

SATISFACTORY

Performance MEETS contractual requirements. The performance of the areas being assessed contains minor issues or concerns, for which corrective actions taken by the Contractor were effective.

MARGINAL

Performance MEETS SOME contractual requirements. The performance of the areas being assessed includes significant problems, issues, or concerns for which corrective actions taken by the Contractor were only somewhat effective.

UNSATISFACTORY

Performance DOES NOT MEET contractual requirement. The performance of the areas being assessed includes serious problems, issues, or concerns for which the Contractor’s corrective actions were ineffective.

NOT APPLICABLE (N/A)

Performance information not recent or relevant as defined in the Solicitation. Unable to provide assessment.

Past Performance Evaluation Question 1. Performance What is your assessment of the Contractor’s ability to meet your requirement (s)?

Performance

Comments, if any.

Questions 2. Schedule/Timeliness What is your assessment of the Contractor’s ability to provide on time services in accordance with the contract requirement (s)?

Timeliness

Ability to Resolve Timeliness Problems

Question 3. Technical (Quality of Services

What is your assessment of the Contractor’s ability to provide quality services (in accordance with, qualified personnel, patient safety, patient interaction, training etc...)?

Quality of Services

Question 4. Management or Business Relations What is your assessment of the Contractor’s ability to manage onsite personnel and communicate effectively with contractor personnel, and the facilities Contracting Officers Representative (COR)?

Quality of Management

Question 5. Overall Rating of Contractor’s performance

What is your overall rating of Contractor’s performance (requirements, schedule, and price) on contract being assessed?

Overall Performance

General Comments:

Question 6. Other

During the period of performance for the above contract, have you ever had to enact a termination, suspension or debarment of the aforementioned Contractor?

General Comments: