D.11 PAST PERFORMANCE QUESTIONNAIRE.pdf

D.11 Past Performance Questionnaire

PAST PERFORMANCE QUESTIONNAIRE

RETURN COMPLETED BY APRIL 30, 2026

RETURN SURVEY FORM TO:

Name: Patricia Trusler Phone Number: 913-946-1115 E-mail: patricia.trusler@va.gov

A. RESPONDENT INFORMATION:

Company/Organization Name Address:

Point of Contact (POC):

Title of POC:

Telephone Number:

Fax Number:

Email

B. EVALUATEE’S INFORMATION:

Company/Organization Name Address:

Telephone Number:

Point of Contact (POC):

Title of POC:

Offeror Performed as: Prime or Sub-Contractor (Check One)

C. CONTRACT OR SERVICE INFORMATION:

Contract Title:

Contract Number:

Status (i.e. On-going, complete):

Contract Amount: total amount of base period plus any options Type of Contract or Service Performance Period:

Include base period plus any options Place of Performance:

mailto:patricia.trusler@va.gov

BRIEF DESCRIPTION OF CONTRACT REQUIREMENTS:

D. 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 “Neutral”.

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.

1 2 3 4 5 6 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 inproviding 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

E. OTHER:

(1) Would you award this contractor 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 ever been given a cure notice, show cause notice, suspension of progress payments, etc.? ( ) Yes, ( ) NoIf 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. Failure to provide comments will render questionnaire void and will not be accepted by the Government)