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 collect contractor performance information for federal contract evaluation purposes. The questionnaire requires contractors to provide comprehensive details about their service delivery, including a description of services performed, performance dates, total contract value, and organizational contact information. Respondents must identify whether they served as the prime contractor, classify the work complexity level (high, medium, or low), and provide contract and task order numbers for reference purposes.

The questionnaire evaluates contractor performance using a three-tier rating system: Outstanding (performance significantly exceeded expectations and accomplished unanticipated goals), Satisfactory (performance met expectations and contract requirements), or Unsatisfactory (performance failed to meet expectations and contract requirements). For any rating other than Satisfactory, contractors must provide detailed explanations including examples of strengths or areas for improvement. Completed questionnaires must be signed and submitted to the contracting officer or designated point of contact by the quote deadline. This template is being used in connection with solicitation 36C25926Q0825 for a Patient Observation Rounding System to support clinical staff in in-patient hospital settings across the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 19.

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Other files

File Type Posted
APPENDIX B VA HANDBOOK 6500.6.pdf PDF
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36C25926Q0825 Patient Observation Rounding System.docx DOCX document
36C25926Q0825.docx DOCX document
APPENDIX C 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 .