D.7 Attachment_Past Performance Questionnaire.docx

PAST PERFORMANCE QUESTIONNAIRE

REFERENCE INSTRUCTIONS: The Department of Veterans Affairs is considering the Offeror detailed below for an award of a VA contract related to Wheelchair Van services for Altoona. Your comments would be appreciated regarding this firm’s past performance. Your comments are considered Source Selection Sensitive in accordance with IAW FAR 2.101 and FAR 3.104. We please ask that the Survey be completed by the evaluator and returned directly to the Contracting Officer at the following email address prior to the established Request for Proposal (RFP) Deadline: cynthia.laemmerhirt@va.gov Special Note: The vendor being evaluated should complete the information detailed below to include the RFP Deadline based upon the information contained in the respective Solicitation.

Solicitation/RFP No.: [Insert] Requiring Activity: [Insert] Contracting Officer Email: [Insert] Return By (Date/Time): [Insert] A. Reference & Contract Information (to be completed by Offeror or CO)

· Offeror (Company) Name:

· Contract/Order Number:

· Customer/Agency/Facility Name:

· Project/Service Title:

· Period of Performance (From/To):

· Total Contract Value:

· Prime/Sub/KP (check one): ☐ Prime ☐ Subcontractor ☐ Key Personnel

· Point of Contact at Customer (Name/Title/Email/Phone):

Special Note: Please Use an individual form for each respective contract being evaluated.

Relevancy Assessment (Required Once Per Contract) How relevant is this contract to the services required in the current VA solicitation?

(Select one. Definitions come from the solicitation and VA Source Selection Guide.)

· ☐ Very Relevant – The work involved essentially the same magnitude of effort and complexities as the instant requirement.

· ☐ Relevant – The work involved similar scope and magnitude of effort and complexities.

· ☐ Somewhat Relevant – The work involved some of the scope and magnitude of effort and complexities.

· ☐ Not Relevant – The work involved little or none of the scope and magnitude of effort and complexities.

Performance Confidence Assessments Rating Method Table 2.

Please evaluate the Confidence Level of what Government should expect from the vendor based upon your company’s experience. Please only use the following ratings without variation. If the rating is LC or NC, please provide additional information in the appropriate block or in the remarks section of this form.

“SubC” = Substantial Confidence = Based on the offeror’s recent/relevant performance record, the Government has a high expectation that the offeror will successfully perform the required effort.

“SATC” = Satisfactory Confidence = Based on the offeror’s recent/relevant performance record, the Government has a reasonable expectation that the offeror will successfully perform the required effort

“LC” = Limited Confidence = Based on the offeror’s recent/relevant performance record, the Government has a low expectation of successful performance.

“NC” = No Confidence = Based on the offeror’s recent/relevant performance record, the Government has no expectation that the offeror will successfully perform the required effort.

“UC” = Unknown Confidence (neutral) = No recent/relevant performance information is available, or the offeror’s performance record is so sparse that no meaningful rating can be assigned.

Please rate and provide information/comments for the following based on the proposal for present and past performance:

Highlight your Selection

Q14. Would you award another contract to the contractor being evaluated? If no, please explain:

Yes | No

Additional Remarks:

Name of Evaluator:

Evaluator’s Company/Organization:

Evaluator’s Signature:

The CO reserves the right to contact the evaluator to corroborate the PPQ.