PAST PERFORMANCE EVALUATION QUESTIONNAIRE.docx
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- Solicitation number
- 36C25723Q0713
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PAST PERFORMANCE EVALUATION QUESTIONNAIRE
36C25723Q0713 Past Performance Questionnaire: The past performance questionnaire must be independently completed by the offeror’s client references. Offerors are responsible for ensuring that their client references complete this questionnaire and submit it via email directly to Elsa Gomez at elsa.gomez@va.gov. 36C25723Q0713- Locum Medical Technologists in the subject line, NO LATER THAN THE DUE DATE AND TIME OF THE SOLICITATION.
Contractor:
Contractor Address:
Contract No:
| Contract Type: |
| ☐Firm Fixed Price |
☐T&M/LH
☐Cost Reimbursement ☐Other (Specify):
Period of Performance:
Role on Project (Prime/Subcontractor):
Dollar Amount:
Agency/Company Name:
Agency/Company POC/Phone/Email:
Title of Contract:
Description of Contract Service/Scope of contract:
Complexity of Work: ☐ Difficult ☐ Moderate ☐ Routine
The following questions pertain to the contractor’s record of past (within the past three years) and current performance. The information that you provide will be used in the awarding of a federal contract. Therefore, it is important that our information be as factual and accurate as possible. Please provide examples and/or explanations (use additional pages if necessary).
NOTE: Please use Past Performance Rating Guidelines included herein.
| Subject Area: |
| Rating |
| A. Quality of Work |
| Unsatisfactory |
Marginal Satisfactory Very Good Exceptional
Comments:
| B. Personnel – Knowledge, Skills and Abilities |
| Unsatisfactory |
Marginal Satisfactory Very Good Exceptional
Comments:
| C. Cost/Budget Control |
| Unsatisfactory |
Marginal Satisfactory Very Good Exceptional
Comments:
| D. Customer Satisfaction |
| Unsatisfactory |
Marginal Satisfactory Very Good Exceptional
Comments:
| E. Timeliness of Performance/ Deliverables |
| Unsatisfactory |
Marginal Satisfactory Very Good Exceptional
Comments:
| F. Business Relations |
| Unsatisfactory |
Marginal Satisfactory Very Good Exceptional
Comments:
| G. Overall Performance |
| Unsatisfactory |
Marginal Satisfactory Very Good Exceptional
Comments:
15. Would you select this contractor again? Please explain.
16. Name and title of individual who completed this questionnaire:
17. Date:
Past Performance Rating Guidelines Summarize contractor performance in each of the rating areas. Assign each area a rating of Unsatisfactory, Marginal, Satisfactory, Very Good, and Exceptional. Use the following instructions as guidance in making these evaluations. Please use the comments area on the preceding form to justify the rating given.
| Ratings |
| Quality of Work/ Personnel Capabilities |
-Compliance w/contract requirements -Accuracy of reports -Appropriateness of personnel -Technical excellence Cost/Budget Control
-Within budget -Current, accurate, complete billings -Relationship of negotiated costs to actual -Cost efficiencies -Change orders issued Customer Satisfaction
Customer Satisfaction is a measure of how products and services supplied by a company meet or surpass customer expectation.
Timeliness of Services/ Deliverables
-Met interim milestones -Reliable -Responsive to technical direction -Completed on time Business Relations
-Effective management -Business like correspondence -Responsive to contract requirements -Prompt notification of problems -Reasonable/ cooperative -Flexible -Pro-active
| Unsatisfactory |
| Nonconformance's are comprising the achievement of contract requirements |
| Cost issues are comprising performance |
| Delays are compromising achievement of contract requirements |
| Response is not effective |
| Marginal |
| Nonconformance's require major agency resources to ensure achievement of contract requirements |
| Cost issues require major agency resources to ensure achievement of contract requirements |
| Delays require major agency resources to ensure achievement of contract requirements |
| Response is marginally effective |
| Satisfactory |
| Nonconformance's do not impact achievement of contract requirements |
| Cost issues do not impact achievement of contract requirements |
| Delays do not impact achievement of contract requirements |
| Response is usually effective |
| Very Good |
| There are no quality problems/issues, and the contractor has substantially exceeded the contract performance requirements without commensurate additional costs to the Government |
| There are no cost management issues and the Contractor has exceeded the contract requirements, achieving cost savings to the Government |
| There are no delays |
| Response to inquiries and/or technical, service, administrative issues are effective. |
| Exceptional |
| The contractor has demonstrated an exceptional performance level that was significantly in excess of anticipated achievements and is commendable as an example for others. It is expected that this rating will be used in those rare circumstances where contractor performance clearly exceeds the performance levels described as "Exceptional". |
| The contractor has demonstrated an exceptional performance. It is expected that this rating will be used in those rare circumstances where the contractor achieved cost savings and performance clearly exceeds the performance levels described as "Exceptional". |
| The contractor has demonstrated an exceptional performance level. It is expected that this rating will be used in those rare circumstances where contractor performance clearly exceeds the performance levels described as "Exceptional" |
| The contractor has demonstrated an exceptional performance level. It is expected that this rating will be used in those rare circumstances where contractor performance clearly exceeds the performance levels described as "Exceptional" |
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