Past Performance Questionnaire.docx

19 KB Posted

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7G20--Pathology Service Dictation Software License Brand Name or Equal To Dragon Medical
Solicitation number
36C25926Q0350
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This is a Past Performance Questionnaire template designed to collect comprehensive information about a contractor's performance on completed federal contracts. The questionnaire requires contractors to provide detailed documentation including the contractor's name, a thorough description of services performed with specific objectives and scope of work, performance dates, total contract value in USD, organizational address, contract and task order numbers, and point of contact information with current phone and email details. Respondents must rate overall performance using three categories—Outstanding (significantly exceeded expectations with unanticipated accomplishments), Satisfactory (met expectations and requirements), or Unsatisfactory (did not meet expectations)—and provide detailed justification for any rating other than Satisfactory, including specific examples of strengths or improvement areas. The questionnaire also requests complexity classification (High, Medium, or Low) and confirmation of prime contractor status.

The completed and signed questionnaire must be submitted to the contracting officer or designated point of contact by the quote deadline. All sections require completion and accurate, current contact information. A verification statement certifies that the information provided is accurate and authorizes verification of the services described. This questionnaire template is associated with RFQ #36C25926Q0350 for a Pathology Service Dictation Software License (Brand Name or Equal To Dragon Medical) issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 19. The RFQ has a quote submission deadline of April 27, 2026, at 3:00 PM MT, with quotes to be submitted via email only to Lindsey.Zwaagstra@va.gov. This is a total small business set-aside for NAICS code 541519 (Information Technology Value Added Resellers) with a 150-employee size standard, and the government anticipates awarding a firm-fixed price contract.

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Pathology Dictation System SOW.docx DOCX document

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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 .