D.10 ATTACHMENT 10 PAST PERFORMANCE SURVEY.36C26127Q0068.docx

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Attached to
Q403--Ergonomic Evaluations (VANCHCS)
Solicitation number
36C26127Q0068
Issued by

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This is a Past Performance Survey template for solicitation 36C26127Q0068, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21 for ergonomic evaluation services (Q403--Ergonomic Evaluations for VANCHCS).

The survey is designed to be completed by references provided by offerors and submitted directly to durell.salaz@va.gov. Offerors must submit a separate completed and signed survey for each reference provided. The survey requests evaluators to document the services provided, including performance dates, dollar amounts, and contract numbers. Evaluators are instructed to rate the contractor's overall quality of work using a scale of Excellent, Good, Fair, Marginal, or Unacceptable, and to provide comments on any performance issues or concerns and how they were addressed. The survey emphasizes that the names of individuals providing reference information will remain confidential and will not be released or made publicly available.

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Past Performance Survey 36C26127Q0068

OFFEROR INSTRUCTIONS: A separate survey must be completed and signed for each reference. The completed surveys must be submitted directly to durell.salaz@va.gov.

EVALUATOR INSTRUCTIONS: The Department of Veterans Affairs is considering the company listed below for award of a VA contract. Your comments would be appreciated regarding this company’s past performance. The name of the individuals providing reference information is confidential and will not be released or made publicly available.

Please Note: When completing this Survey be sure to summarize what service(s) you provided on the contract(s) to include the performance dates, dollar amount(s) and contract number(s).

Name of Company being evaluated:

Evaluator’s Name and signature: Must be signed

Evaluator’s Company Name, Address and Phone number:

Indicate what services did this company provided for you? Provide the total contract amount, dates of performance, and contract number.

Evaluation Questions

Please rate the overall quality of work using a scale of (Excellent, Good, Fair, Marginal, Unacceptable). Comments in support of the rating are welcome.

Were there any performance issues/concerns? If so, how were they handled?

How did the Contractor perform on the contract?

Were there any issues and how did they handle them?

File details come from the government source that posted it. Updated .