Past Performance Questionnaire.docx

19 KB Posted

Attached to
H146--Critical Water Testing Amendment to at LOS
Solicitation number
36C25926Q0773
Issued by

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This is a Past Performance Questionnaire template designed to collect and evaluate contractor performance data for federal contracting purposes. The questionnaire requires contractors to provide comprehensive documentation of services performed, including detailed descriptions of scope, objectives, and achievements or challenges encountered. Respondents must supply critical administrative information such as contractor name, performance dates, total contract value, organization addresses, contract and task order numbers, and points of contact with current phone and email details.

The questionnaire uses a three-tier performance rating system—Outstanding, Satisfactory, or Unsatisfactory—with required justification and examples for ratings other than Satisfactory. Contractors must complete all sections and return the signed questionnaire to the contracting officer or designated point of contact by the quote deadline. The form indicates whether the contractor served as prime or subcontractor and requires complexity level designation (High, Medium, or Low). This template is intended for use with the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 19 in connection with solicitation 36C25926Q0773 for H146--Critical Water Testing services, which involves critical and utility water sample collection, testing, and reporting on ionic characteristics.

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Other files

File Type Posted
VA Notice of Limitations on Subcontracting.docx DOCX document
36C25926Q0773 0001.docx DOCX document
36C25926Q0773.docx DOCX document
852.219-75 VA Notice of Limitations on Subcontracting - Certificate of Compliance for Services and Construction.docx DOCX document
Statement of Work.docx DOCX document
36C259Q0773 Solicitation.docx DOCX document
Wage Determination 2015-5489 Rev 30.pdf PDF

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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 .