Past Performance Questioanaire.docx

D.2 PRESENT/PAST PERFORMANCE SURVEY

A. GENERAL INFORMATION: Please correct any information below known to be inaccurate.

Solicitation Number: 36C24622Q0388_1 Preventive Maintenance & repairs on Medical Gas and Vacuum Pump Systems with Hydrocarbon testing

Contractor's Name: ___________________________________________________________________

Address: ___________________________________________________________________________ Telephone/Email: ____________________________________________________________________

Point of Contact: _____________________________________________________________________

Service Provided: _____________________________________________________________________

Number and type of Contracts: __________________________________________________________

Contractor Performed as the ( ) prime Contractor, or the ( ) Sub-Contractor

1. RESPONDENT INFORMATION:

Name of Respondent: ___________________________Title: __________________________________

Organization: ________________________________________________________________________

Address: ____________________________________________________________________________

Email: _________________________________________

Telephone Number: ____________________________Fax Number: _____________________________

SIGNATURE______________________________________

1. EMAIL COMPLETED SURVEY FORM TO: Paul Waite paul.waite@va.gov

PAST AND PRESENT PERFORMANCE SURVEY

1. PERFORMANCE INFORMATION: Choose and circle the number on the scale of 1-6 that most accurately describes the contractor's performance or situation.

CODE/PERFORMANCE LEVEL

1 UNSATISFACTORY - Performance did not meet most contractual requirement. There were serious problems and the contractor's corrective actions were ineffective.

2 MARGINAL - Performance did not meet some contractual requirements. There were problems, some of a serious nature, for which corrective action was only marginally effective.

3 NONE - No record of past performance or the record is inconclusive.

4 SATISFACTORY - Performance met contract requirements. There were some minor problems and corrective actions taken by the contractor was satisfactory.

5 VERY GOOD - 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.

6 EXCEPTIONAL – Performance met all contract requirements and exceeded many to the government’s benefit. Problems, if any, were negligible and were resolved in a timely, highly efficient manner.

The contractor: (1 being Very Bad and 6 being Very Good)

Remarks______________________________________________________________________

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