Past Performance Questionnaire.docx

19 KB Posted

Attached to
DA01--Patient Observation Rounding System
Solicitation number
36C25926Q0825
Issued by

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This is a Past Performance Questionnaire template designed to solicit and document contractor performance information related to federal contract opportunities. The questionnaire requires contractors to provide comprehensive details about their past work, including a description of services performed, contract performance dates, total contract value, organizational addresses, contract and task order numbers, and designated points of contact. Contractors must rate their overall performance using three categories—Outstanding, Satisfactory, or Unsatisfactory—with corresponding definitions, and provide additional comments and justification for ratings other than Satisfactory.

The questionnaire is applicable to the Department of Veterans Affairs Veterans Health Administration solicitation for a Patient Observation Rounding System (Solicitation Number 36C25926Q0825), which seeks a proximity-required patient monitoring and compliance system designed for use in hospital inpatient settings, emergency departments, behavioral health units, recovery facilities, residential care, skilled nursing facilities, and long-term care environments. Contractors must complete all sections, ensure accuracy of contact information, and submit a signed questionnaire to the contracting officer or designated point of contact by the quote deadline. The template includes sections to identify whether the contractor is a prime contractor, assess contract complexity (High, Medium, or Low), and obtain verification of the accuracy and completeness of the information provided.

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Other files

File Type Posted
Wage Determination 2015-5489 Rev 31.pdf PDF
36C25926Q0825 Patient Observation Rounding System.docx DOCX document
36C25926Q0825.docx DOCX document
APPENDIX C VA HANDBOOK 6500.6.pdf PDF
APPENDIX B VA HANDBOOK 6500.6.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 .