Exhibit N- PAST PERFORMANCE QUESTIONNAIRE.pdf

36C24925R0008 Exhibit N

PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for LaGrange CBOC

PAST PERFORMANCE INSTRUCTIONS

The NCO 9 Network Contracting Activity, Murfreesboro, Tennessee has issued a solicitation to provide leased space for a Community Based Outpatient Clinic (LaGrange

CBOC).

Past performance information will be used to evaluate proposals received. Section A is to be completed by the Offeror. Section A of the enclosed questionnaire lists the contractor who has identified your office as a source to evaluate their past performance. Section A also authorizes release of this information to NCO 9 Network Contracting Activity, Murfreesboro, Tennessee.

The Offeror must provide this entire document to each of its assessors. The Offeror shall only submit with its proposal (by the closing date of the Solicitation) copies of Section A of the questionnaire as provided to the assessors.

Section B in its entirety is to be completed by the assessor(s). An individual assessor knowledgeable of the contractor’s quality of supplies and services rendered is requested to verify, complete the questionnaire, and submit to the Contracting Office. If evaluating more than one contract for the same contractor, use a separate questionnaire for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing your assessment is greatly appreciated. The questionnaire should be completed as soon as possible but not later than (10/15/25, 3:00PM CST). Assessor is requested to send electronically to Angela.Bailey5@va.gov. Assessor: Please do not send this information to the Offeror being evaluated.

Thank you in advance for your cooperation and expeditious response to this request.

PAST PERFORMANCE QUESTIONNAIRE

SECTION A: Contractor Information (to be completed by the contractor for who past performance information is being collected, prior to forwarding to assessors)

Solicitation Number 36C24925R0008 Project/Requirement LaGrange CBOC Customer/Agency Department of the Veteran Affairs, NCO 9, Murfreesboro, TN 37219

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 9 Network Contracting Activity, Murfreesboro, Tennessee

(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

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

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 contractors 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?

______ 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.

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

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/Contracting Officer Technical Project Lead/Project Officer

OTHERS

(Signature) (Date) (Typed or Printed Name) (Organization Name)

(Phone Number)

Assessor Name