D.5 Past Performance Questionnaire.docx

Controlled Unclassified Information When completed, this document is Source Selection Information IAW FAR 2.101 and 3.104.

Section L Attachment: Past Performance Questionnaire – Sample 3 The Department of Veterans Affairs, Network Contracting Office 10 is in the process of competitively selecting a source for the Ambulance Services program to provide Special Mode Travel services for the organizations.

One of the considerations in proposal evaluation is the verification of the offerors' past performance on contracts or other work efforts which reflect the offeror's ability to perform on the proposed effort. We depend on information received from organizations such as yours, which have had first-hand experience with the offeror, for the evaluation of the offeror's performance on those contracts or work efforts.

Our areas of interest regarding the offeror are summarized in the enclosed questionnaire. In order to meet the acquisition milestones, we request your written response no later than 11 July 2026, 1pm EST. This schedule will allow us sufficient time to analyze the data prior to the start of offer evaluations.

To assist you in preparing your response and expediting your reply, the questionnaire may be filled out electronically and e-mailed to robert.bolcavage@va.gov . Your completed questionnaire will become a part of the official source selection records.

Your assistance is greatly appreciated, and your prompt response will be one of the keys to the successful and timely completion of this Source Selection.

Robert J. Bolcavage III Contracting Specialist

1 Atch Past Performance Questionnaire

Section 1: Contract Identification

A. Contractor (Company/Division):

B. Contractor Cage Code:

C. Contract Number:

D. Contract Type (e.g., FFP, FPIF, CPIF, CPFF, etc.):

E. Program Title:

F. Brief Program Description:

G. Program Phase (e.g., Engineering & Manufacturing Development (EMD)):

H. Period of Performance

1. Original Schedule (assuming all options exercised):

Beginning Date _____________________

2. Current Schedule (assuming all options exercised):

Beginning Date _____________________

3. Reason for difference (if applicable):

I. Contract Dollar Value

1. Original maximum contract dollar value (assuming all options exercised): $

2. Current maximum contract dollar value (assuming all options exercised): $

3. Reasons for difference between original and current contract dollar value (if applicable):

J. Description of work performed:

K. Was this a competitively awarded contract? ☐ Yes ☐ No

L. Contractor’s Role: ☐ Prime Contractor ☐ Subcontractor ☐ Key Personnel

Note: If offeror holds or has held other contracts with your agency/organization in the last three (3) years, please complete separate Past Performance Questionnaire forms for those contracts as well.

Section 2: Customer or Agency Identification

A. Customer or agency name:

B. Customer or agency description (if applicable):

C. Geographic description of work performed under this contract (i.e., local, nationwide, worldwide, other Commands):

Section 3: Respondent Identification

A. Respondent’s name:

B. Respondent’s title:

C. Respondent’s phone/fax number/e-mail address:

D. Length of time (number of years/months) respondent worked on subject contract and description of responsibility/position/role:

E. Other suggested points of contact:

Section 4: Performance Information

In the table below, indicate your rating for the contractor’s performance by placing an “X” in the appropriate block to the right of each question. Provide supporting information for each response in the space provided. Attach additional pages if more space is needed. The performance rating scale is defined as follows:

Code Performance Rating

E EXCEPTIONAL – Performance meets contractual requirements and exceeds many requirements to the Government’s benefit. The contractual performance being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

V VERY GOOD – Performance meets contractual requirements and exceeds some requirements to the Government’s benefit. The contractual performance being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

S SATISFACTORY – Performance meets contractual requirements. The contractual performance being assessed contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

M MARGINAL – Performance does not meet some contractual requirements. The contractual performance being assessed reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented.

U UNSATISFACTORY – Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

N/A NOT APPLICABLE – Unable to provide a rating. Contract did not include performance for this aspect, performance was not observed, or information was not available. Do not know.

Note: The following are SAMPLE questions. Past Performance evaluation teams MUST construct a simple and concise Past Performance Questionnaire, tailored to seek out key information tied to the significant aspects of the planned acquisition. Avoid questions that can be answered with a “yes” or “no” but instead include probing and direct questions to draw out the required information desired.

1. Provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements.

SUPPORTING INFORMATION:

2. Demonstrated the ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period.

3. Delegated authority to project managers and supervisors commensurate with contract requirements.

4. Home office participated in solving significant local problems.

5. Followed approved quality control plan.

6. Provided effective quality control and/or inspection procedures to meet contract requirements.

7. Corrected deficiencies in timely manner and pursuant to their quality control procedures.

8. Provided timely resolution of contract discrepancies.

9. Identified problems as they occurred.

10. Suggested alternative approaches to problems.

11. Displayed initiative to solve problems.

12. Developed realistic progress schedules.

13. Met established project schedules.

14. Was responsive to contract changes.

15. Provided adequate project supervision.

16. Paid subcontractors/suppliers in a timely manner.

17. Cooperated with Government personnel after award.

18. How would you rate the contractor's overall performance on this contract?

19. Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain.

EXPLANATION:

☐ Yes ☐ No

20. Would you award another contract to this contractor? If not, explain.

EXPLANATION:

☐ Yes ☐ No

IF THIS WAS A GOVERNMENT CONTRACT:

Did this contract include FAR 52.219-9, Small Business Subcontracting Plan?

☐ Yes ☐ No

If yes, did the contractor comply with the clause? Please explain.

Did this contract include FAR 52.219-8, Utilization of Small Business Concerns?

☐ Yes ☐ No

If yes, did the contractor comply with the clause? Please explain.

Additional remarks:

[click and pick the date]

Respondent’s Signature Date

Thank you for your prompt response and assistance!

Please return this completed questionnaire to:

Mailing Address:

[Insert here]

FAX to:

E-Mail to:

Controlled Unclassified Information Page 7 of 7