D.10 PAST PERFORMANCE SURVEY.pdf
PDF 169 KB Posted
- Attached to
- Sterile Compounding Services
- Solicitation number
- 36C25727Q0032
About this file
This is a Past Performance Survey form (version 1.1) for federal contract 36C25727Q0032. The document is a template to be completed by reference organizations that have direct knowledge of an offeror's performance on previous contracts. Completed surveys must be sent directly from the reference organization—not the offeror—via email to Stephanie.Reeves@va.gov and Shannon.Hodgson@va.gov by November 4, 2026.
Section A requires general information about the contractor, including the contractor's name and address, contract number, contract dollar value, Contracting Officer Representative (COR) contact information, and Contracting Officer contact information. Section B provides space to describe services performed. Section C presents a performance rating scale from 1 to 6, where 1 represents Unsatisfactory performance, 2 represents Marginal, 3 represents None (no record of performance), 4 represents Satisfactory, 5 represents Very Good, and 6 represents Exceptional. The form requires detailed comments for any Unsatisfactory or Marginal ratings and as appropriate for other answers, with the option to attach additional sheets if needed.
The survey addresses eight performance evaluation criteria completed by the delegated COR: (1) provision of experienced/qualified personnel, (2) ability to hire, maintain, and replace qualified personnel with coverage during leave, (3) meeting established schedules, (4) cooperation with government personnel, (5) timely resolution of contract discrepancies, (6) work quality meeting or exceeding acceptable levels, (7) suggesting alternative problem-solving approaches, and (8) displaying initiative to solve problems. Question 9 asks whether the reference organization would recommend awarding another contract to the contractor. The form concludes with space for additional comments and requires the COR's signature and date.
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Text version
PAST PERFORMANCE SURVEY
36C25727Q0032
Past Performance Form version 1.1 1 of 4
D.10 PAST PERFORMANCE SURVEY
Past Performance Surveys must be completed by the organization (reference) that has direct knowledge of the Offeror’s performance on previous contracts.
Completed surveys shall be sent directly from the reference organization (not the Offeror) via email to both of the following addresses:
Stephanie.Reeves@va.gov
Shannon.Hodgson@va.gov
Return surveys NLT November 4, 2026.
A. GENERAL INFORMATION:
Contractor's Name:
Contractor’s Address:
Contract #:
Contract Dollar Value:
COR:
COR’s Ph #:
Contracting Officer:
Contracting Officer’s Ph #:
B. SERVICES PERFORMED:
C. PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 6 that most accurately describes the contractor's performance or situation.
1 - Unsatisfactory. Performance did not meet most contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective.
2 - Marginal. Performance did not meet some contractual requirements. There were problems and the contractor’s corrective actions were ineffective.
mailto:Stephanie.Reeves@va.gov mailto:Francisco.Mendoza@va.gov
Past Performance Form version 1.1 2 of 4
3 - None. No record of past performance or the record is inconclusive.
4 - Satisfactory. Performance met contract requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory.
5 - Very Good. Performance met all contract requirements and exceeded some to the government’s benefit. There were few minor problems which the contractor resolved in a timely, effective manner.
6 - Exceptional. Performance met all contract requirements and exceeded many to the government’s benefit. Problems, if any were negligible and were resolved in a timely, highly efficient manner.
E. Please provide comments for all questions in which an Unsatisfactory or Marginal rating is given and as appropriate for all other answers. Space for your comments is provided in each area. If more space is needed, attach additional sheets to the end of the questionnaire and reference the respective question.
TO BE COMPLETED BY THE DELEGATED COR
The contractor:
1. Provided experienced/qualified personnel to perform services.
1 2 3 4 5 6 N/A
Remarks______________________________________________________________________
2. Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period. Also provide coverage with qualified personnel during periods of leave or absence .
Remarks_____________________________________________________________________
3. Met established schedules.
Past Performance Form version 1.1 3 of 4
4. Cooperated with Government personnel after award.
5. Provided timely resolution of contract discrepancies
6. Performed work that met or exceeded acceptable levels.
7. Suggested alternative approaches to problems.
8. Displayed initiative to solve problems.
9. Would you recommend award of another contract to this contractor? Yes No
Past Performance Form version 1.1 4 of 4
Additional Comments: __________________________________________________________
Signature of COR date
File details come from the government source that posted it. Updated .