D5 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 cynthia.laemmerhirt@va.gov, prior to the established Request for Quotation (RFQ) Deadline:

Special Note: The vendor being evaluated should complete the information detailed below to include the RFQ 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 History & Contract Information (to be completed by Past Performance Predecessor Company/Evaluator)

· Company/Division name:

· Customer/Agency/Facility name and Phone Number:

· Product/Service:

· Contract Number:

· Project Title or Brief Description of Work

· Contract Dollar Value:

· Period of Performance (From/To):

· Indication Work Performed as Prime

· Subcontractor, if any

· Key Personnel

· Verified, up-to-date name, title, email address, and telephone number of a reliable point of contact.

· Comments regarding compliance with contract terms and conditions

· Comments regarding any known performance deemed unacceptable to the customer, or not in accordance with the contract terms and conditions.

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

Performance Confidence Assessments Rating Method Table 2.

Questions below shall be completed.

Q1. Describe how the contractor complies with contract requirements?

Q2. Describe how timely was the contractor’s performance?

Q3. Describe how well does / did the contractor comply with labor and safety standards?

Q4. Describe the effectiveness of the contractor’s management of the contract.

Q5. Describe the contractor’s ability to meet various time periods to ensure requests for service response time meets SOW requirements.

Q6. Describe the contractor’s communication.

Q9. Describe the contractor’s handling of staff integrity issues.

Q10. Describe the contractor’s willingness to improve and correct noncompliance issues and concerns.

Q11. Describe the contractor’s timeliness in providing any administrative reports/ documents required by your contract.

Q12. Describe the contractor’s personnel management practices.

Q13. Quality control: Describe the overall quality of the contractor’s work.

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

Additional Remarks:

Name of Evaluator:

Evaluator’s Company/Organization:

Phone Number:

Email:

Evaluator’s Signature:

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