PAST PERFORMANCE QUESTIONNAIRE.docx

PAST PERFORMANCE QUESTIONNAIRE

RFP NUMBER: 36C24223Q0795

TITLE: Water Treatment Services (Northport VA Medical Center) OFFER / QUESTIONNAIRE DUE DATE: June 16, 2023, by 3:00 pm ET

SECTION I: OFFERORS: COMPLETE requested information (Section I) and PROVIDE the questionnaire to the appropriate Respondent for each source of Past Performance Information mentioned in your Offer. The Respondent must have significant familiarity with the selected contract or subcontract to provide informed answers and comments about various aspects of the past performance.

NAME OF OFFEROR:

NAME OF PAST PERFORMANCE REFERENCE:

CONTRACT NUMBER & DATES OF SERVICE:

DESCRIPTION OF SERVICE:

TOTAL AWARD PRICE:

SECTION II: RESPONDENT(S): COMPLETE the requested information (Section II) concerning the past performance of the above named Offeror relative to the referenced contract effort. To select the applicable response, double-click the box and select “Checked” for Default value.

NAME OF RESPONDENT:

TITLE/POSITION:

SIGNATURE:

(A) QUALITY OF SERVICE

1. Did the contractor comply with all contract requirements? |_| Yes |_| No

Comments:

2. Regarding timeliness of performance, were turnaround times of the contract met (i.e. completion of administrative requirements, task orders, milestones, production, and delivery requirements?) |_| Yes |_| No

Comments:

3. Was the contractor's work found to be accurate and technically/clinically sound?

|_| Yes |_| No Comments:

4. How would you rate the quality of the contractor's end products / services furnished under this contract? |_| Outstanding |_| Good |_| Acceptable |_| Unacceptable

Comments:

5. How would you rate the quality of the contractor's customer service furnished under this contract? |_| Outstanding |_| Good |_| Acceptable |_| Unacceptable

Comments:

(B) BUSINESS RELATIONS

5. Was contract Management efficient and responsive?

|_| Always |_| Most of the time |_| Sometimes |_| Never

6. Did the contractor exhibit effective communication(s)?

|_| Always |_| Most of the time |_| Sometimes |_| Never

7. Did the contractor exhibit reasonable and cooperative behavior?

|_| Always |_| Most of the time |_| Sometimes |_| Never

8. Was the contractor flexible?

|_| Always |_| Most of the time |_| Sometimes |_| Never

9. Did the contractor recommend effective solutions to problems?

|_| Always |_| Most of the time |_| Sometimes |_| Never

10. Did the contractor exhibit a business-like concern for the interests of your Agency or Business:

|_| Always |_| Most of the time |_| Sometimes |_| Never

11. How would you rate the contractor in the area of business relations generally?

|_| Outstanding |_| Good |_| Acceptable |_| Unacceptable

Comments on questions 6 through 11 above:

(C) CUSTOMER SATISFACTION

12. How would you rate the contractor based on customer (end-user) satisfaction?

|_| Outstanding |_| Good |_| Acceptable |_| Unacceptable

13. Would you select this firm again? |_| Yes |_| No

Comments:

End of Section II

SECTION

III:

COMPLETED

FORM

MUST

BE

RETURNED

TO

THE

VA

CONTRACTING

OFFICE

PRIOR

TO

THE

DUE

DATE

FOR

RECEIPT

OF

PROPOSALS

THE OFFEROR MAY SUBMIT THE COMPLETED QUESTIONNAIRE

ALONG

WITH

HIS/HER

PROPOSAL;

OR

THE

RESPONDENT

PROVIDING

THE

PERFORMANCE INFORMATION HEREIN MAY FORWARD THE COMPLETED FORM

DIRECTLY TO THE CONTRACTING

OFFICE,

IF

PREFERRED.

IN ALL CASES, THE COMPLETED PAST PERFORMANCE REFERENCES MUST REACH

THE CONTRACTING

OFFICE

BY THE

DATE AND

TIME

OFFERS

ARE

DUE.

THE

GOVERNMENT

BEARS

NO

RESPONSIBILITY

TO

ASSURE

QUESTIONNAIRES

ARE

PROPERLY

RECEIVED.

POC: Andres Cepeda Contracting Officer

NCO 02

Lyons, NJ Phone: 908-647-0180 X4457 Email (preferred): andres.cepeda@va.gov