Past Performance Questionnaire.docx

DOCX document 19 KB Posted

Attached to
6640--New Blanket Purchase Agreement for Molecular Testing- Strep ID, Respiratory Panel, and Blood Culture ID.
Solicitation number
36C25926Q0375
Issued by

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This is a Past Performance Questionnaire template designed for contractors bidding on or performing work related to molecular diagnostic testing services. The questionnaire is associated with solicitation 36C25926Q0375, a Department of Veterans Affairs Veterans Health Administration (VISN 19) RFQ for Strep ID, Respiratory Panel, and Blood Culture ID testing services, which will replace the existing contract 36C25923A0007.

The questionnaire requires contractors to provide comprehensive documentation of their relevant past performance, including detailed descriptions of services performed, performance dates, total contract values, organizational and point-of-contact information, and contract numbers. Respondents must rate their overall performance using a three-tier system: Outstanding (exceeded expectations and accomplished unanticipated goals), Satisfactory (met expectations and contract requirements), or Unsatisfactory (did not meet expectations). The template specifies that responses must be completed, signed, and submitted to the contracting officer or designated point of contact by the quote deadline. Contractors must also indicate whether they served as a prime contractor and assess the complexity level of the work performed (High, Medium, or Low). This questionnaire serves as a mechanism for the VA to evaluate contractor qualifications and historical performance before awarding the new molecular diagnostic testing contract covering multiple VA facilities in Montana, including VA Montana Healthcare at Fort Harrison and the VA Clinic in Billings.

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Past Performance Questionnaire Strep ID, Respiratory Panel, and Blood Culture ID Cost Per Test (CPT) VA Montana Haalthcare, Fort Harrison, MT Benjamin Steele VA Clinic, Billings, MT 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 .