Exhibit T - Past Performance Form-Questionaire.pdf

Past Performance Questionnaire Page 1 of 6

RLP No.: _____________________

PAST PERFORMANCE QUESTIONNAIRE

CONTRACT INFORMATION (Offeror to complete Blocks 1-4)

1. OFFEROR INFORMATION

Past Performance Reference No.: _____________________________________________________________ Offeror Name: _____________________________________________________________________________ Address: _________________________________________________________________________________ Phone Number:_______________________________ DUNs Number: ________________________________ Contact Name: ____________________________________________________________________________ Email Address: _______________________________ Contact Phone Number: _________________________

2. GENERAL WORK INFORMATION

Work performed as: Offering Entity Key Personnel Percent (%) of project work performed by Offering Entity or Key Personnel: _____________________________ List of Major Subcontractor(s) and Role(s):_______________________________________________________

3. CONTRACT INFORMATION

Contract Number: __________________________________________________________________________ Contractor Name - Contract Awarded To: _______________________________________________________ Contractor Contact Name: ___________________________________________________________________ Phone:_________________________________________ Email: ____________________________________ Contract Type: Firm Fixed Price Cost Reimbursement Other (Please explain) Contract Title: _____________________________________________________________________________ Contract Location: __________________________________________________________________________ Award Date (mm/dd/yy): ___________________________________________ Construction Completion Date (mm/dd/yy): _____________________________ Awardee Ongoing Services: _________________________________________ Original Contract Price (Award Amount): _______________________________ Final Contract Price (to include all modifications, if applicable): _______________________________________

REFERENCE INFORMATION

Past Performance Questionnaire Reference

Name & Title:

Phone No.:

Email:

Address:

Contracting Officer (CO) or Individual Responsible for Signing Contract

Name & Title:

Phone No.:

Resident Engineer/COR’s Technical Representative

Name & Title:

Phone No.:

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PAST PERFORMANCE QUESTIONNAIRE (CONTINUED)

4. PROJECT DESCRIPTION

Type of Work (check all that apply): VA Federal Medical Office Other:_______________ Reference Project Key Personnel Assigned as Key to Lease Project: Yes No If yes, please provide key personnel names and roles:

KEY PERSONNEL NAMES AND ROLES

DETAILED DESCRIPTION OF THE WORK PERFORMED

EXPLANATION OF RELEVANCY TO RLP REQUIREMENTS

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INSTRUCTIONS FOR REFERENCES COMPLETING THIS QUESTIONNAIRE: VA requests that the Offerors’s Reference completes this questionnaire and submits it directly back to VA’s Contract Officer/Specialist at Lisa Newlin at Lisa.Newlin@va.gov no later than ___________PM Local Time on _________________, 2021 with a subject line that reads RLP No. ___________________, [Name of Offeror], Completed Past Performance Questionnaire”.

The government reserves the right to verify all information on this form.

Use the following adjective ratings and definitions in your evaluation of the Contractor’s performance.

RATING DEFINITION NOTE

(E) Exceptional Performance meets contractual requirements and exceeds many to the Government benefit.

The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor was highly effective.

An Exceptional rating is appropriate when the Contractor successfully performed multiple significant events that were of benefit to the Government. A singular benefit, however, could be of such magnitude that it alone constitutes an Exceptional rating. Also, there should have been NO significant weaknesses identified.

(VG) Very Good Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

A Very Good rating is appropriate when the Contractor successfully performed a significant event that was a benefit to the Government. There should have been no significant weaknesses identified.

(S) Satisfactory Performance meets minimum contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

A Satisfactory rating is appropriate when there were only minor problems, or major problems that the contractor recovered from without impact to the contract. There should have been NO significant weaknesses identified. Per VA policy, a fundamental principle of assigning ratings is that contractors will not be assessed a rating lower than Satisfactory solely for not performing beyond the requirements of the contract.

(M) Marginal Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor's proposed actions appear only marginally effective or were not fully implemented.

A Marginal is appropriate when a significant event occurred that the contractor had trouble overcoming which impacted the Government.

(U) Unsatisfactory Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains serious problem(s) for which the contractor's corrective actions appear or were ineffective.

An Unsatisfactory rating is appropriate when multiple significant events occurred that the contractor had trouble overcoming and which impacted the Government. A singular problem, however, could be of such serious magnitude that it alone constitutes an unsatisfactory rating.

(N) Not Applicable No information or did not apply to your contract Rating will be neither positive nor negative.

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TO BE COMPLETED BY PPQ REFERENCE

PPQ REFERENCE

PPQ Reference Point of Contact Information:______________________________________________________ Name: ______________________________________________________________________________________ Title: _______________________________________________ Agency/Company: ____________________________________ Phone Number: ______________________________________ Email Address: ______________________________________

Contract No.: _______________________________________ Contract Type: _______________________________________ Contract Title: ________________________________________ Contract Location: ________________________

Describe your role in the project:

Does the narrative in No. 4, above, accurately describe the scope, complexity, and relevance?

Date Questionnaire was completed (mm/dd/yy):

PPQ Reference’s Signature:

Instructions: Please select the adjective rating that best reflects your evaluation of the contractor’s performance.

1. QUALITY: E VG S M U N

(a) Quality of building design, construction, workmanship, quality of materials used, interior spaces, and overall appearance.

(b) Ability to meet quality standards specified for technical performance.

(c) Timeliness/effectiveness of contract problem resolution without extensive customer guidance.

(d) Adequacy/effectiveness of quality control program and adherence to contract quality assurance requirements (without adverse effect on performance).

2. SCHEDULE/TIMELINESS OF PERFORMANCE: E VG S M U N

(a) Compliance with contract delivery/completion schedules including any significant intermediate milestones. (If the schedule was not met, please address below.)

(b) Rate the contractor’s use of available resources to accomplish tasks identified in the contract.

(c) Rate your satisfaction with the contractor’s ability to respond to questions and/or comments in a timely manner.

3. CUSTOMER SATISFACTION: E VG S M U N

(a) To what extent were the end users satisfied with the project?

(b) Contractor was reasonable and cooperative in dealing with your staff (including the ability to successfully resolve disagreements/disputes;

responsiveness to administrative reports, businesslike and communication).

(c) To what extent was the contractor cooperative, businesslike, and concerned with the interests of the customer?

(d) Overall customer satisfaction.

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4. MANAGEMENT/ PERSONNEL/LABOR E VG S M U N

(a) Effectiveness of management, including management of subcontractors and/or labor force?

(b) Ability to hire, apply, and retain a qualified workforce to this effort.

(c) Government Information Property Control.

(d) Knowledge/expertise demonstrated by contractor key personnel.

(e) Government contract requiring a subcontracting plan (Complete if the contractor was required to submit and adhere to a small business subcontracting plan. Were small business goals met?

(f) Ability to simultaneously manage multiple projects with multiple disciplines.

(g) Ability to assimilate and incorporate changes in requirements and/or priority, including planning, execution and response to Government changes.

(h) Effectiveness of overall management (including ability to effectively lead, manage and control the project).

5. COST/FINANCIAL MANAGEMENT E VG S M U N

(a) Ability to meet the terms and conditions within the contractually agreed price(s)?

(b) Contractor proposed innovative alternative methods/processes that reduced cost, improved maintainability or other factors that benefited the

PM.

(c) Is the Contractor’s accounting system adequate for management and tracking of costs? (If no, please explain in comment section below.) Yes No

(d) If this is/was a Government contract, has/was this contract been partially or completely terminated for default or convenience or are there any pending terminations? (Indicate if show cause or cure notices were issued, or any default action in comment section below.)

Yes No

(e) Have there been any indications that the contractor has had any financial problems? (If yes, please explain in the comment section below.) Yes No

6. SAFETY/SECURITY E VG S M U N

(a) To what extent was the contractor able to maintain an environment of safety, adhere to its approved safety plan, and respond to safety issues?

(Includes: following the users’ rules, regulations, and requirements regarding housekeeping, safety, correction of noted deficiencies, etc.).

(b) Contractor complied with all general and IT security requirements for the project and personnel security requirements.

7. GENERAL E VG S M U N

(a) Ability to successfully respond to emergency and/or surge situations (including notifying COR or Contracting Officer in a timely manner regarding urgent contractual issues).

(b) Compliance with contractual terms/provisions (If there were specific issues, please explain in the comments sections below

(c) In summary, provide an overall rating for the work performed by this contractor.

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8. SUMMARY

Would you hire or work with this firm again? (If no, please explain in the comments section below.) Yes No

COMMENTS SECTION

Please provide responses to the above questions (if applicable) and/or additional remarks. Also, please provide a brief narrative addressing specific strengths, weaknesses, deficiencies, or other comments which may assist our office in evaluating performance risk (please attach additional pages if necessary):

SIGNATURE

Signature: ___________________________________________________________________________________ Name: ______________________________________________________________________________________ Date: _____________________________________________ Title: ______________________________________________ Phone Number: _____________________________________ Email Address: ______________________________________