EXHIBIT N (4) - Past Performance Reference update to Radiation Therapy.pdf
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- Solicitation number
- 36C25525R0016
About this file
This document is a Past Performance Reference Check form from the U.S. Department of Veterans Affairs, designed to gather detailed feedback about a contractor's performance on a specific project. The form provides a comprehensive evaluation framework with a 0-10 rating scale across multiple performance categories, including building quality, services, project management, cost control, timeliness, business relations, and overall performance.
The reference check seeks qualitative and quantitative assessments in key areas such as workmanship, time commitment, project management methods, budget adherence, schedule performance, team collaboration, problem resolution skills, and willingness to work together again. The form is specifically associated with the Radiation Therapy VA Clinic Lease (Solicitation Number 36C25525R0016) and is intended to help evaluate a contractor's past performance for a potential future contract with the Department of Veterans Affairs.
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PAST PERFORMANCE REFERENCE CHECK
U.S. DEPARTMENT OF VETERANS AFFAIRS
I.YOU ARE BEING CONTACTED FOR A REFERENCE REGARDING THE PERFORMANCE OF (Insert Business Name and Representative).
OFFEROR INSTRUCTIONS: The Offerors are to fill out the TOP part of this form.
II. Project Name:
Project Address:
City and State:
Type of Project:
Net Usable Square Footage:
III. Name of Company/ Government Agency Employing Reference:
IV. Name and Title of Individual Providing Reference Responses:
Name: Title:
Phone Number: email address:
Current Address:
V. Was this design/build?
VI. Does the information in II above accurately describe your project, and if not, please explain.
VII. What was your role in the project?
VIII. What was the duration of the project?
IX. Please describe the types of services the firm/person provided:
AS APPLICABLE to the role he or she had on the team, please provide responses to the following questions using a scale of 0 to 10 with zero being the lowest rating and 10 being the highest rating.
9-10 Significantly Exceeded Expectations 7 -8 Met and to Some Extent Exceeded Expectations 5-6 Met Expectations 3-4 Did Not Fully Meet Expectations 0-2 Failed to Meet Expectations
X. QUALITY OF BUILDING AND SERVICES
A. BUILDlNG
1. For the building, how satisfied were you with workmanship, quality of materials used and overall appearance? 0 1 2 3 4 5 6 7 8 9 10 Enter number chosen here. [ ]
2. Provide information to support your numerical evaluation above.
3. For the interior spaces, how satisfied were you with the efficiency of the space and flexibility for future space changes? 0 1 2 3 4 5 6 7 8 9 10 Enter number chosen here. [ ]
4. Provide information to support your numerical evaluation above.
B. SERVICES
1. For the person named above, how satisfied were you with his or her time commitment to the project? 0 1 2 3 4 5 6 7 8 9 10 Enter number chosen here. [ ]
2. Provide information to support your numerical evaluation above.
C. PROJECT MANAGEMENT
1. For the person named above, how satisfied were you with the quality of his or her project management methods (or design if the person named above was an architectural designer) and his or her response to unanticipated problems? 0 1 2 3 4 5 6 7 8 9 10 Enter number chosen here. [ ]
2. Provide information to support your numerical evaluation above.
D. COST CONTROL
1. For the person named above, how satisfied were you with his or her commitment to your budget? 0 1 2 3 4 5 6 7 8 9 10 Enter number chosen here. [ ]
2. Provide information to support your numerical evaluation above.
3. How satisfied were you with the handling and pricing of change orders?
0 1 2 3 4 5 6 7 8 9 19 Enter number chosen here. [ ]
4. Provide information to support your numerical evaluation above.
E. TIMELINESS OF PERFORMANCE
1. How satisfied were you with his or her ability to stay on schedule?
0 1 2 3 4 5 6 7 8 9 10 Enter number chosen here. [ ]
2. Provide information to support your numerical evaluation above.
3. How satisfied were you with his or her ability to respond to any of your questions and comments in a timely manner? 0 1 2 3 4 5 6 7 8 9 10 Enter number chosen here. [ ]
4. Provide information to support your numerical evaluation above.
F. BUSINESS RELATIONS
1. For the person named above, how satisfied were you with his or her working relationship between the project team members? 0 1 2 3 4 5 6 7 8 9 10 Enter number chosen here. [ ]
2. Provide information to support your numerical evaluation above.
3. How satisfied were you with his or her problem resolution skills?
0 1 2 3 4 5 6 7 8 9 10Enter number chosen here. [ ]
4. Provide information to support your numerical evaluation above.
G. GOVERNMENT CONTRACT REQUIRING A SUBCONTRACTING PLAN (Complete this if you are providing a reference for the Offeror only if the referenced project was a Government contract requiring a subcontracting plan.)
1. Did the firm meet subcontractor and Small Disadvantaged Business goals and file the required 294's and 295's? YES [ ] NO [ ]
2. Were any claims or mechanics liens filed in connection with this project? YES [ ] NO [ ] If yes, please explain:
3. Would you contract with them again? YES [ ] NO [ ]
H. OVERALL SCORE
1. What is your overall score for the COMPANY OR PERSON named above?
0 1 2 3 4 5 6 7 8 9 10 Enter number chosen here. [ ]
2. Provide information to support your numerical evaluation above.
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