D.4 ATTACHMENT 4 PAST PERFORMANCE SURVEY.docx
DOCX document 17 KB Posted
- Solicitation number
- 36C26126Q0812
About this file
This is a Past Performance Survey template for federal contract evaluation in response to solicitation 36C26126Q0812 from the Department of Veterans Affairs Veterans Health Administration, Veterans Integrated Service Network 21. The survey is designed to be completed by offerors as a separate document for each reference and must be submitted directly to durell.salaz@va.gov for evaluation purposes.
The template requests comprehensive information about a contractor's past performance on relevant contracts, including the contracting activity name and address, contract number, award and performance dates, contract value, contract type, and points of contact for both technical and contracting matters. Offerors must provide details on the place of performance, a description of work performed, any commendations or awards received, and a list of major subcontractors. The completed surveys will be used to evaluate contractor qualifications for the VA contract opportunity related to curriculum development, policy analysis, and community engagement addressing cultural, structural, and institutional barriers for VAPIHCS. Evaluator instructions indicate that responses will be kept confidential and the identity of reference providers will not be released or made publicly available.
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Text version
PAST PERFORMANCE SURVEY
36C26126Q0812
OFFEROR INSTRUCTIONS: A separate survey must be completed 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.
1. Name of Contracting Activity, Government Agency, Commercial Firm, or other Organization being evaluated:
2. Contracting Activity Address (Name, Address and Phone number):
3. Contract Number:
4. Date of Contract Award:
5. Beginning Date of Contract:
6. Completion Date of Contract:
7. Contract Value:
8. Type of Contract:
9a. Technical Point of Contact:
9b. Contracting Point of Contact:
10. Place of Performance:
11. Description of Work (Use a continuation sheet if necessary):
12. List any commendations or awards received:
13. List of Major Subcontractors:
14. Required Signature:
File details come from the government source that posted it. Updated .