EXH Q PastPerf Questionnaire Draft VA Horizon City TX.docx
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- Solicitation number
- 36C24W26R0013
- Issued by
-
Department of Veterans Affairs
About this file
This is a Past Performance Questionnaire template designed to collect contractor performance information for evaluation purposes in federal contracting. The document is specifically formatted for assessing a contractor's performance on a VA Community-Based Outpatient Clinic (CBOC) lease in Horizon City, Texas (Solicitation Number 36C24W23N0012), though it serves as a reusable template for other contract evaluations as well.
The questionnaire is divided into two main sections: Section A requests contractor information including company name, point of contact, contract award details, period of performance, and contract amount; and Section B, completed by assessors, evaluates contractor performance across four primary categories—Quality of Service, Schedule, Business Relations, and Overall Performance. The rating scale uses five designations: Exceptional/Very Low Risk (E), Satisfactory/Low Risk (S), Marginal/Moderate Risk (M), Unsatisfactory/High Risk (U), and Neutral/Unknown Risk (N). Assessment criteria under Quality of Service include compliance with contractual requirements and overall quality. Schedule ratings address timeliness of service delivery and invoice accuracy and timeliness. Business Relations evaluations encompass business practices, management relationships, report submission timeliness, and complaint resolution responsiveness. The questionnaire concludes with an assessment of willingness to award future contracts and requests overall performance ratings and general comments from the assessor, who must identify their role (Contract Specialist/Lease Contracting Officer, Technical Project Lead, or other) and period of involvement.
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Text version
12/30/20
PAST PERFORMANCE QUESTIONNAIRE
SECTION A: Contractor Information (to be completed by the contractor for whom past performance information is being collected, prior to forwarding to assessors)
| Solicitation Number |
| 36C24W23N0012 |
| Project/Requirement |
| VA/CBOC in Horizon City, TX |
| Customer/Agency |
| VHA |
1. Prospective Government Contractor’s ______________________________________
| Name and Address: | ______________________________________ | |
| ______________________________________ | ||
| ______________________________________ |
2. Contractor Point of Contact: ___________________________________________
3. Phone number (with area code): ___________________________________________
4. Assessor Contract Award number: _________________________________________
5. Description of Services provided under contract: ________________________________________________________________________
6. Contract award date: ___________ Contract Amount: Initial ___________Final ____
7. Period of Performance or Delivery Date: _________________________
ASSESSOR INFORMATION:
Assessor Name
Title
Phone Number/Email Address
8. Authorization is hereby granted to provide the information requested in this questionnaire to NCO 21 Network Contracting Activity, Jeffrey Deering, Lease Contracting Officer, via email at Jeffrey.deering@va.gov.
(Signature)
| _____________________________________________ | __________________________ | |
| (Name and Title of Authorizing Official) | (Date) |
SECTION B: Assessors Information (to be completed by assessors).
RATING SCALE Definitions Past Performance Ratings and Definitions
| E |
| Exceptional/Very Low Risk |
| Offer’s past performance record provides essentially no doubt that the offeror will successfully perform the required effort. |
| S |
| Satisfactory/Low Risk |
| Offer’s past performance record provides little doubt that the offeror will successfully perform the required effort. |
| M |
| Marginal/Moderate Risk |
| Offer’s past performance record, although satisfactory, provides some doubt that the offeror will successfully perform the required effort. |
| U |
| Unsatisfactory/High Risk |
| Offer’s past performance record provides substantial doubt that the offeror will successfully perform the required effort. |
| N |
| Neutral/Unknown Risk |
| The offeror has no relevant past performance record. A thorough search was unable to identify any past performance. Will not rate favorably or unfavorably. |
The questions on the survey (see below) shall be rated in accordance with the definitions provided in the Rating Scale. Any unsatisfactory or marginal rating shall be supplemented with an explanation in the space provided.
QUALITY OF SERVICE
1. Rate the contractor’s compliance with contractual requirements. _________ (E /S /M /U /N)
2. Overall rating of contractor quality of service. _________ (E /S /M /U /N)
PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:
SCHEDULE
1. Delivery of service was within required time period specified by contract requirements. _________ (E /S /M /U /N)
2. Rate the contractor’s ability to control cost and submit invoices.
Are invoices complete, accurate, and timely? _________ (E /S /M /U /N)
BUSINESS RELATIONS
1. Overall rating of contractor’s business practices (e.g., maintaining A positive working relationship, business ethics, timely and effectively Resolution of any problems, etc.) _________ (E /S /M /U /N)
2. Rate the working relationship between contractor’s management, and your company (i.e., contractor’s history of reasonable and cooperative behavior, commitment of customer satisfaction; concern for the interest of the customer). _________ (E /S /M /U /N)
3. Rate the contractor's ability to submit required reports and/or invoices in a timely manner. _________ (E /S /M /U /N)
4. Rate the contractor’s responsiveness to customer complaint resolution. _________ (E /S /M /U /N)
5. Overall rating of contractor’s business relations. _________ (E /S /M /U /N)
PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:
How would you feel about awarding another contract to this contractor? (Mark with an “X”)
| ______ | Would not hesitate to award another contract to this contractor. |
| ______ | Would most likely award another contract to this contractor. |
| ______ | Would think twice about awarding another contract to this contractor but would do so if no better alternative existed. |
| ______ | Do not wish to award another contract to this contractor. |
| ______ | Would not award another contract to this contractor. |
Overall Rating of Contractor’s performance (quality, schedule, business relations,) on contract being assessed.
| Exceptional |
| Satisfactory |
| Marginal |
| Unsatisfactory |
| Neutral |
VII. General Comments:
ASSESSOR:
Identify your role in the contract award or administration and the period of your involvement.
| Role |
| Period of Involvement |
Contract Specialist/LEASE CONTRACTING OFFICER
Technical Project Lead/Project Officer
OTHERS
| ________________________________________ | ____________________________ | |
| (Signature) | (Date) |
(Typed or Printed Name) (Organization Name)
| ____________________________ | _________________________ | |
| (Phone Number) | (Email) |
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