EXHIBIT D - Past Perfomance Questionnaire.docx
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- Solicitation number
- 36C24426R0139
About this file
This is a Past Performance Questionnaire template used by the Department of Veterans Affairs Network Contracting Office to evaluate contractor performance on reference projects. Offerors must complete the contractor information section and distribute the form to past performance references, who then submit completed questionnaires directly to Contract Specialist Amanda Murphy at Amanda.Murphy5@va.gov prior to the Request for Proposal due date.
The questionnaire evaluates contractor performance across six categories using a scale from 0 (Neutral) to 5 (Exceptional). Quality Management & Workmanship assessment includes evaluation of experienced management, personnel qualification and retention, quality control procedures, timely deficiency correction, compliant submittals, and problem-solving approaches. Timeliness and Schedule Adherence covers notice of delays, submission timeliness, and realistic schedule development. Business Practices and Customer Relationship evaluation addresses problem-solving initiative, independent performance without excessive government oversight, subcontractor management, and timely change order proposals. Compliance & Safety section assesses report accuracy, adherence to federal laws and regulations including construction wage rates and environmental requirements, and jobsite safety program compliance. The questionnaire also includes an Infection Control section specific to VA requirements and Overall Customer Satisfaction criteria evaluating cost reasonableness of modifications, cure/show cause notices, and willingness to award future contracts. Reference contacts must provide an overall performance rating and detailed remarks explaining their assessments, then certify the accuracy of their responses.
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Text version
Department of Veterans Affairs
Network Contracting Office 4 1010 Delafield Road Pittsburgh, PA 15215
Past Performance Questionnaire for:
INSTRUCTIONS TO OFFEROR
Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). Save the document. Send an electronic copy 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 Contract Specialist via email to:
Contract Specialist Amanda Murphy Amanda.Murphy5@va.gov
Please return the completed form ASAP, but no later than the Request for Proposal due date.
If you have any questions, please contact the Contract Specialist: Amanda.Murphy5@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.” |
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| YES |
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| 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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