D.11 Past Performance Contacts.pdf
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- Solicitation number
- 36C25525R0011
About this file
This is a Past Performance Assessment Questionnaire form that must be completed by three references for offerors bidding on Healthcare for Homeless Veterans (HCHV) services under solicitation 36C25525R0011. The questionnaire must be submitted directly by the references (not the offeror) to Contract Specialist Jessica Hansroth via email at maria.owen2@va.gov by the solicitation due date.
The assessment evaluates contractors on a 1-6 scale across multiple performance categories including quality of service, price control, timeliness/schedule, business relationships, and key personnel. The rating scale ranges from Unsatisfactory (2) to Exceptional (6), with detailed risk level definitions provided for each rating. The form requires references to provide basic contract information, rate specific performance elements, indicate if they would award another contract to the offeror, note any contract terminations or cure notices, and provide an overall performance rating. Written justification is required for any Unsatisfactory, Marginal, Very Good, or Exceptional ratings. Only past performance references from the previous three years for HCHV services are eligible for consideration.
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PERFORMANCE RISK ASSESSMENT QUESTIONNAIRE
Past Performance Survey
The Offeror is to provide this form to a minimum of three (3) current/past performance references for Health Care for Homeless Veteran (HCHV) services conducted within the past three years, to include the names and phone numbers of responsible individuals who would have firsthand knowledge of the performance.
Questionnaires are to be returned via email by the Offeror’s Reference to Jessica Hansroth, Contract
Specialist at maria.owen2@va.gov. The email subject line should include 36C25525R0011, Past
Performance Questionnaire.
Questionnaires are to be returned by the Solicitation’s due date/time identified on the SF 1449, block 8, unless it has been extended via Solicitation Amendment.
Questionnaires submitted by the Offeror will not be considered.
Business Name: _____________________________________________________________
Business Address: ___________________________________________________________
Contact Person: ___________________________ Title: ____________________________
Email Address: ______________________________________________________________
Telephone Number: _________________________ Contract Value: $__________________
Contract Number/Reference: ___________________________________________________
Contract Period of Performance Dates: ___________________________________________ mailto:maria.owen2@va.gov
BRIEF DESCRIPTION OF SERVICES PROVIDED:
PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 6 that most accurately describes the offeror’s performance or situation. If you are unable to rate an item because it was not a requirement, never an issue, or you have no knowledge of the item in question, then you should mark “NA”.
Exceptional. (6) Performance meets contractual requirements and exceeds many requirements to the government’s benefit. (Risk Level: Very Low)
Very Good. (5) Performance meets contractual requirements and exceeds some to the government’s benefit.
(Risk Level: Low)
Satisfactory. (4) Performance meets contractual requirements. (Risk Level: Moderate)
Marginal. (3) Performance does not meet some contractual requirements. The element being assessed reflects a serious problem for which the contractor has not yet implemented satisfactory corrective actions. (Risk Level:
High)
Unsatisfactory. (2) Performance does not meet contractual requirements and recovery is not likely in a timely manner. Contractor’s corrective actions to date are ineffective (Risk Level: Very High)
Unknown. (1) The offeror has little/no relevant past performance upon which to base a meaningful performance risk prediction. (Risk Level: Unknown)
a. QUALITY OF PRODUCT OR SERVICE:
(1) The Contractor provided services that conformed to contract requirements, specifications, and standards of safety.
1 2 3 4 5 6 NA
(2) The Contractor submitted accurate reports/surveys. 1 2 3 4 5 6 NA
(3) The Contractor utilized personnel that were appropriate to the effort performed.
1 2 3 4 5 6 NA
(4) The Contractor established and maintained adequate management of subcontractors to ensure quality service.
1 2 3 4 5 6 NA
b. PRICE CONTROL:
(1) The Contractor performed the effort within the cost/price. 1 2 3 4 5 6 NA
(2) The Contractor submitted accurate invoices on a timely basis. 1 2 3 4 5 6 NA
c. TIMELINESS/SCHEDULE:
(1) The tasks required under this effort were performed in a timely manner and in accordance with the period of performance of the contract.
1 2 3 4 5 6 NA
(2) The Contractor was responsive to technical and/or contractual direction. 1 2 3 4 5 6 NA
d. BUSINESS RELATIONSHIPS:
(1) The Contractor demonstrated effective management over the effort performed. 1 2 3 4 5 6 NA
(2) The Contractor maintained an open line of communication so that the Contracting Officer’s Representative (COR) was apprised of technical, cost, and safety issues.
NA
(3) The Contractor presented information, reports, surveys and correspondence in a clear, concise, and businesslike manner.
1 2 3 4 5 6 NA
(4) The Contractor promptly notified the COR and/or Contracting Officer in a timely manner regarding urgent issues.
1 2 3 4 5 6 NA
(5) The Contractor cooperated with the Government in providing flexible, proactive, and effective recommended solutions to critical contract issues.
1 2 3 4 5 6 NA
e. KEY PERSONNEL:
(1) The Contractor provided qualified personnel to fulfill the requirements of the contract.
1 2 3 4 5 6 NA
A. OTHER:
(1) Would you award this contractor/offeror another contract? ( ) Yes, ( ) No If you answered “No” provide an explanation.
(2) Was the contract terminated for default? ( ) Yes, ( ) No If you answered “Yes”, provide an explanation.
(3) Has the contractor/offeror ever been given a cure notice, show cause notice, suspension of progress payments, etc.? ( ) Yes, ( ) No If you answered “Yes”, provide an explanation.
(4) Based upon the information you provided and using the definitions provided in the evaluation criteria above, the overall performance rating you would give this contractor is:
Exceptional , Very Good , Satisfactory , Marginal , Unsatisfactory , Unknown , COMMENTS: (ALL Unsatisfactory, Marginal, Very Good, or Exceptional Ratings require comments to support the same.)
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