D.4 Attachment Past Performance Questionnaire.docx
DOCX document 48 KB Posted
- Attached to
- G-004 HealthCare for Homeless Veterans (HCHV) for Battle Creek, MI VA Medical Center 36C25025Q0507
- Solicitation number
- 36C25025Q0507
About this file
This document is a Past Performance Questionnaire for a Request for Quotation (RFQ) 36C25025Q0507 for Healthcare for Homeless Veterans (HCHV) services at the Battle Creek VA Medical Center. The questionnaire is designed to assess a contractor's past performance across multiple evaluation criteria, including timely service completion, compliance with contract terms, personnel quality, quality control procedures, regulatory compliance, problem-solving abilities, and overall performance.
The document requests past performance evaluators to complete and return the questionnaire by August 29, 2025, via email to angela.freel@va.gov. Evaluators are asked to rate the contractor's performance using a scale from Outstanding to Unacceptable across ten specific performance dimensions, with the option to provide narrative explanations. The questionnaire will help the Department of Veterans Affairs Veterans Health Administration assess a potential contractor's capabilities for providing HCHV services in Grand Rapids, Michigan, with the goal of determining the contractor's suitability for future contract awards.
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Other files
| File | Type | Posted |
|---|---|---|
| Solicitation 36C25025Q0507.docx | DOCX document | |
| D.1 Attachment QASP Quality Assurance Surveillance Plan.docx | DOCX document | |
| D.2 Attachment Wage Determination 2015-4847.docx | DOCX document | |
| D.3 Attachment Contractor Cert of Compliance Immigration.docx | DOCX document | |
| D.5 Attachment 852.222-71 Compliance with Executive Order 13899.docx | DOCX document |
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Text version
PAST PERFORMANCE QUESTIONNAIRE
REQUEST FOR QUOTATION (RFQ) 36C25025Q0507
HCHV Services Battle Creek VA Medical Center
MESSAGE TO THE EVALUATOR: Your assistance is requested by Angela Higgins, Contracting Officer to assist with establishing the performance history for the Company (Offeror) named below. In efforts to expedite receipt of the requested information, the Contracting Office respectfully requests that you do not mail hard copies. Instead, please e-mail the completed past performance questionnaire(s) to: angela.freel@va.gov. If enough space is not provided, then please attach additional information to this questionnaire. Please provide the survey back on or before August 29, 2025.
1. Name of Offeror /Agency:
Contract Number:
Title/Description of Contract:
Period of Performance:
Based upon the definitions below, indicate your assessment of the offeror’s performance. Your assessment should consider the offeror’s performance in accordance with the contractual requirements. Please include the period of performance and contract value:
2. Brief description of scope of work:
EVALUATION: Please rate the offeror using the guide and the pull-down menus in the evaluation table below. Explanatory narratives for as many responses as possible would be appreciated. These narratives need not be lengthy, just detailed. Attach additional pages if more space is needed.
| ASSESSMENT |
| DEFINITION |
| Outstanding (O) |
| The Offeror’s performance met contractual requirements and exceeded many requirements to the Client’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the offeror were highly effective. |
| Above Average (A) |
| The Offeror’s performance met contractual requirements and exceeded some requirements to the Client’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the offeror were effective. |
| Satisfactory (S) |
| The Offeror’s performance met contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the offeror were satisfactory. |
| Unacceptable (U) |
| Performance did not meet contractual requirements. The contractual performance reflected a serious problem for which the offeror has yet to identify corrective actions or the offeror’s proposed actions appear only marginally effective or were not fully implemented. |
| Completed scheduled services in a timely manner per the Performance Work Statement (PWS). |
| Choose an item. |
| Compliance with contractual Terms and Conditions. |
| Choose an item. |
| Provided experienced personnel with sufficient technical and administrative abilities needed to meet contract requirements. |
| Choose an item. |
| Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period. |
| Choose an item. |
| Provided effective quality control and/or inspection procedures to meet contract requirements. |
| Choose an item. |
| Corrected deficiencies in timely manner and pursuant to the offeror’s quality control procedures. |
| Choose an item. |
| Exhibited knowledge of and compliance with Government (or other) regulations and industry standards. |
| Choose an item. |
| Effectively responded to urgent requests in a timely manner per the Performance Work Statement (PWS). |
| Choose an item. |
| Solved contract performance problems without extensive guidance from procurement or technical personnel. |
| Choose an item. |
| Provided timely and accurate documents, records, and invoices as required by the contract. |
| Choose an item. |
| Rate the Offeror’s OVERALL quality of performance under this contract |
| Choose an item. |
Would you award similar contracts to this offeror? Please provide explanation for response.
EXPLANATION OF OVERALL RATING GIVEN:
ADDITIONAL COMMENTS (use additional pages as required)
ASSESSOR NAME AND INFORMATION
Name & Signature of Assessor’s:
Company/Agency: Date:
Position Title/Grade: Contracting Officer Phone:
Email: Fax:
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