EXHIBIT C - Past Performance Questionnaire V1.docx
DOCX document 546 KB Posted
- Solicitation number
- 36C24226R0116
About this file
This is a Past Performance Questionnaire template for the Department of Veterans Affairs contract 528A8-CSI-806, which involves renovating four rooms (A214-A217) on the second floor of the A-Wing MRI Section at Stratton VA Medical Center in Albany, New York to accommodate installation of a new Philips 1.5T MRI unit. The questionnaire is designed to be completed by past performance reference contacts to evaluate a contractor's performance on relevant projects.
The form evaluates contractor performance across six key categories: Quality-Management & Workmanship (six evaluation items covering manager experience, personnel qualification, quality control procedures, deficiency correction, submittal clarity, and problem-solving approach); Timeliness and Adherence to Schedule (three items addressing delay notifications, submittal timeliness, and schedule development); Business Practices/Customer Relationship and Ability to Perform (four items evaluating problem-solving initiative, independent work capability, subcontractor management, and change order proposals); Compliance & Safety (three items covering report submission, federal law compliance, and safety program compliance); Infection Control (one item specific to infection control process compliance); and Overall Customer Satisfaction (three items addressing modification cost reasonableness, cure notices, and contractor award willingness). Reference contacts rate performance on a 0-5 scale (Neutral to Exceptional) with detailed performance descriptors for each rating level and must provide remarks explaining their overall rating. Completed forms must be submitted to Ryan.Seburn@va.gov by 10:00 am local time on September 14th, 2026.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24226R0116_3.docx | DOCX document | |
| 36C24226R0116_2.docx | DOCX document | |
| 36C24226R0116_1.docx | DOCX document | |
| EXHIBIT B-Sample Transmittal Letter for Past Performance Evaluation Questionnaire.docx | DOCX document | |
| Final-SOW-Renovate A214-A217 for New MRI.docx | DOCX document | |
| 36C24226R0116.docx | DOCX document |
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Text version
Department of Veterans Affairs
Network Contracting Office 4 1010 Delafield Road Pittsburgh, PA 15215
Past Performance Questionnaire for: 528A8-CSI-806 Renovate A214-A217 for New MRI
INSTRUCTIONS TO OFFEROR
Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and submit it according to the instructions, below.
Company Name
Street Address
Point of Contact (POC)
City
POC Phone Number
State
Reference Project Title
Zip Code
Contract Period of Performance (start to finish):
Contract Number
Contract Dollar Value
Description of Work
| Role of Contractor on This Project (check appropriate box) |
| |_| Prime Contractor |_| Sub-contractor |_| Key Personnel |
INSTRUCTIONS TO REFERENCE CONTACT
The contractor named above is submitting a proposal for a United States Department of Veterans Affairs contract, and has sent this form to you as a past performance reference contact. Please complete the following pages in full (all areas shaded in light yellow, below). Once completed, please send the form to the Contracting Officer by emailing directly to:
Ryan.Seburn@va.gov
Please return the completed form ASAP, but no later than 10:00 am local time, September 14th, 2026.
If you have any questions, please contact the Contract Specialist: Ryan.Seburn@va.gov
RESPONDENT INFORMATION [completed by Reference Contact]
Company Name
Street Address
POC Name
City
Phone Number
State
Zip Code
PERFORMANCE INFORMATION: Choose the number on the scale of 0 (Neutral) to 5 (Exceptional) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE AN EXPLANATION FOR THE OVERALL RATING in the Remarks section, below.
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| NEUTRAL |
| UNACCEPTABLE |
| MARGINAL |
| ACCEPTABLE |
| VERY GOOD |
| OUTSTANDING |
| No record of past performance, or not applicable or the record is inconclusive. |
| Performance did not meet most contractual requirements. There were serious problems and the contractor’s corrective actions were ineffective. |
| Performance did not meet some contractual requirements. There were problems, some of a serious nature, for which corrective action was only marginally effective. |
| Performance met most contractual requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory. |
| Performance met all contract requirements and exceeded some to the government’s benefit. There were a few minor problems, which the contractor resolved in a timely, effective manner. |
| Performance exceeded all contract requirements. There were no problems. |
| The Contractor … |
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
QUALITY – MANAGEMENT & WORKMANSHIP
| 1. |
| Provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements. |
| |_| |
| |_| |
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| 2. |
| Demonstrated ability to hire, maintain, and replace, if necessary, qualified construction personnel during the contract period. |
| |_| |
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| 3. |
| Provided and followed approved quality control plan and/or inspection procedures to meet contract requirements. |
| |_| |
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| 4. |
| Corrected deficiencies in timely manner and pursuant to their quality control procedures. |
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| 5. |
| Submittals clearly identified the proposed item IAW the specifications and drawings. |
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| 6. |
| Suggested alternative approaches to problems. |
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TIMELINESS AND ADHERENCE TO SCHEDULE
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| 7. |
| Contractor provided timely notices of possible delays/schedule revisions. |
REMARKS:
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| 8. |
| Timeliness in submitting submittals and reports and responding to agency inquiries, RFP's, etc. |
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| 9. |
| Developed realistic and met approved progress schedules. |
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BUSINESS PRACTICES/CUSTOMER RELATIONSHIP AND ABILITY TO PERFORM
| 10. |
| Displayed initiative to solve problems. |
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| 11. |
| How well did the contractor work independent of Government guidance, oversight and assistance? |
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| 12. |
| Subcontractors / tradesmen were adequately managed and coordinated. Explain any subcontracting issues (positive or negative) that impacted the performance of your contract(s). |
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| 13. |
| For contract changes, contractor provided timely and realistic change order proposals. |
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COMPLIANCE & SAFETY
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| 14. |
| Reports (i.e., daily, test, logs) / records were submitted completely and accurately satisfy the requirement. |
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| 15. |
| Applicable to Federal Contracts –Contractor complied with applicable Federal Laws and Regulations such as Construction Wage Rate Requirements – timely payrolls and compliance; Drug-Free Workplace; Environmental Regulations and Use of Recovered Materials; Executive Order 13101 Greening the Government. |
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| 16. |
| Contractor’s safety program was in compliance with federal regulations. Contractor implemented and followed their safety plan and ran a “safe jobsite”. |
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INFECTION CONTROL
| 17. |
| Contractor had an Infection Control Process in place and complied with agency Infection Control Requirements. |
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OVERALL CUSTOMER SATISFACTION
| 18. |
| Demonstrated reasonableness in modifications cost proposal. |
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| 19. |
| Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.” |
| |_| |
| YES |
| |_| |
| NO |
| 20. |
| Would you award another contract to this contractor? If not, please explain in “remarks.” |
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| YES |
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| NO |
| OVERALL PERFORMANCE RATING: |
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REMARKS (Please use as much space as is needed – the box will expand as you type).
I hereby certify that the information that I have reported above is accurate to the best of my knowledge.
Printed Name
E-mail address
Business Title
Signature
Date
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