Past Performance Questionnaire.docx

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Q301--Prostate Testing for Salt Lake City VA Medical Center
Solicitation number
36C25926Q0178
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This is a Past Performance Questionnaire template designed to evaluate contractor performance on federal contracts. The document requires contractors to provide comprehensive information about services performed, including detailed descriptions of objectives, scope of work, and achievements or challenges. Contractors must complete all sections with accurate contact information and submit signed questionnaires to the contracting officer by the quote deadline. The form captures essential contract details including performance dates, total contract value, contract and task order numbers, organizational addresses, and points of contact.

The questionnaire employs a three-tier performance rating system: Outstanding (performance significantly exceeded expectations and accomplished unanticipated goals), Satisfactory (performance met expectations and requirements), and Unsatisfactory (performance did not meet expectations and requirements). Respondents must indicate whether the contractor served as a prime contractor and assess complexity level (High, Medium, Low). For ratings other than Satisfactory, the questionnaire requires lengthy explanations with specific examples of contractor strengths or improvement areas. The document concludes with a verification section requiring authorized signature, name, title, and date to certify accuracy and completeness of the information provided.

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Past Performance Questionnaire Instructions:

1. Complete all sections of the questionnaire.

2. Ensure all contact information is accurate and up-to-date.

3. Have the contractor send a signed and completed questionnaire to the contracting officer or designated point of contact by the quote deadline.

1. Name of contractor being reviewed:

2. Description of Services Performed:

· Please provide a detailed description of the services performed under this contract. Include any specific objectives, scope of work, and notable achievements or challenges encountered.

· Prime contractor? Yes or no

· Complexity: ☐ HIGH ☐MEDIUM ☐LOW

3. Performance Dates:

· Start Date (MM/DD/YYYY):

· End Date (MM/DD/YYYY):

4. Total Contract Value:

· Please provide the total value of the contract (in USD):

5. Addresses:

Organization Name:

Street Address:

City:

State:

ZIP Code:

6. Contract Numbers:

· Contract Number:

· Task Order Number (if applicable):

7. Point of Contact Information:

· Name:

· Title:

· Phone Number:

· Email Address:

8. Performance Rating:

· Please rate the overall performance of the contractor according to the following criteria:

· Outstanding: Performance significantly exceeded expectations in all essential areas and accomplished goals that were not anticipated.

· Satisfactory: Performance met expectations and contract requirements.

· Unsatisfactory: Performance did not meet expectations and contract requirements.

· Please check the appropriate rating:

· ☐ Outstanding

· ☐ Satisfactory

· ☐ Unsatisfactory

· Additional Comments (if rated other than satisfactory): Lengthy explanation or justification for the given rating, including examples of the contractor's strengths or areas for improvement:

Verification:

· The information provided above is accurate and complete to the best of my knowledge. I authorize the verification of the services performed as described.

Signature: Please sign as indicated below Name:_________________________ Title:___________________________ Date:__________________________

File details come from the government source that posted it. Updated .