D.7 ATTACHMENT G Past Performance Questionnaire.docx

ATTACHMENT F - PAST PERFORMANCE QUESTIONNAIRE

PART 1 (TO BE COMPLETED BY THE OFFEROR)

Provide the following information requested in this format for each of the projects/contracts being described. Projects may be on going or have been completed within five (5) years prior to the solicitation issue date. Provide accurate information on the contracts you identify. The form may be re-typed or copied into a new solicitation enclosure; however, all questions must be answered, and all information must be provided.

Respondent Information for Solicitation: 36C24822R0028 – Chemistry Automated Laboratory System – VA Orlando Healthcare System

1. Contractor Name:

0. Point of Contact:

0. Title:

0. Email:

0. Phone:

1. Project/Contract Title:

1. Contract Specifics:

2. Contract Number:

2. Total Contract Value:

2. Period of Performance:

2. Number of Vehicles providing services:

2. Description of Services provided:

6. Setting: □ Hospital or Medical Clinic □ Other

Authorization is hereby granted to provide the information requested in this questionnaire to NCO 8, Orlando, Florida.

(Signature)

(Name & Title of Authorizing Official) (Date)

PART 2 (TO BE COMPLETED BY THE ASSESSOR)

The intent of this form is to evaluate the Offeror’s past performance with your company. Information provided is considered sensitive; therefore, the release of individual’s names providing reference information about Offeror’s past performance will not be disclosed and will remain with the contracting office.

This survey should be completed by an assessor with sufficient familiarity of the Offeror’s performance and returned by the assessor no later than the offer due date and time of the solicitation to christopher.bany@va.gov and jessica.kiser@va.gov. Please reference “36C24822R0028 Past Performance/Company Name” in the subject field of your email.

RATING SCALE Definitions

Not Applicable

No performance record identifiable within the area of evaluation.

The questions in the survey (see below) shall be rated in accordance with the definitions provided in the Rating Scale above. Any unsatisfactory or marginal rating shall be supplemented with an explanation in the space provided below.

Please provide straightforward responses and/or additional remarks. Furthermore, please provide a brief narrative addressing specific strengths, weaknesses, deficiencies, or other comments which may assist our office in evaluating performance risk (attach additional pages if necessary)

Signature of Assessor / Evaluator Date

Name:

Title:

Email