Past Performance Questionnaire.pdf

Procurement Sensitive Do Not Disclose --- See FAR Subparts 2.101 and 3.104-4 FOR

OFFICIAL USE ONLY

PAST PERFORMANCE QUESTIONNAIRE

SECTION A: Contractor Information (to be completed by the contractor for who past performance information is being collected, prior to forwarding to assessors)

Solicitation Number 36C24924R0079 Project/Requirement Project 596A4-19-106 Customer/Agency Lexington VA Healthcare System

1. Prospective Government Contractor’s __________________________________________________

Name and Address __________________________________________________

2. Contractor Point of Contact: __________________________________________________

3. Phone Number (with area code): __________________________________________________

4. Assessor Contract Award Number: __________________________________________________

5. Description of Services: __________________________________________________

6. Contract Award Date: _______________ Contract Amount: Initial ___________ Final___________

7. Period of Performance: __________________________________________________

ASSESSOR INFORMATION:

Assessor Name Title Phone Number/Email Address

8. Authorization is hereby granted to provide the information requested in this questionnaire to

NCO 9 Network Contracting Activity, Murfreesboro, Tennessee.

Signature

Name and Title of Authorizing Official Date

SECTION B: Assessors Information (to be completed by assessors).

RATING SCALE Definitions

Past performance Evaluation Ratings Rating Description ACCEPTABLE Based on the Offeror's performance record, the

Government has a reasonable expectation that the offeror will successfully perform the required effort, or the Offeror's performance record is unknown. (See note below.)

UNACCEPTABLE

Based on the Offeror's performance record, the Government has no reasonable expectation that the offeror will be able to successfully perform the required effort.

The questions on the survey (see below) shall be rated in accordance with the definitions provided in the Rating Scale. Any unsatisfactory or marginal rating shall be supplemented with an explanation in the space provided.

QUALITY OF SERVICE

1. Rate the contractor's compliance with contractual requirements.

ACCEPTABLE_______ UNACCEPTABLE_______

2. Overall rating of contractor quality of service.

ACCEPTABLE_______ UNACCEPTABLE_______

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

SCHEDULE

3. Delivery of service was within required time period specified by contract requirements.

ACCEPTABLE_______ UNACCEPTABLE_______

4. Rate the contractor's ability to control cost and submit invoices.

Are invoices complete, accurate, and timely?

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

BUSINESS RELATIONS

5. Overall rating of contractor's business practices (e.g. maintaining a positive working relationship, business ethics, timely and effectively resolution of any problems, etc.)

ACCEPTABLE_______ UNACCEPTABLE_______

6. Rate the working relationship between contractor's management, and your company (i.e. contractor's history of reasonable and cooperative behavior, commitment of customer satisfaction; concern for the interest of the customer).

ACCEPTABLE_______ UNACCEPTABLE_______

7. Rate the contractor's ability to submit required reports and/or invoices in a timely manner.

8. Rate the contractor's responsiveness to customer complaint resolution.

9. Overall rating of contractor's business relations.

How would you feel about awarding another contract to this contractor?

__________ Would not hesitate to award another contract to this contractor.

__________ Would most likely award another contract to this contractor.

__________ Would think twice about awarding another contract to this contractor but would do so if no better alternative existed.

__________ Do not wish to award another contact to this contractor.

__________ Would not award another contract to this contractor.

Overall rating of contractor's performance (quality, schedule, business relations,) on contract being assessed.

ACCEPTABLE UNACCEPTABLE

VII. General Comments:

ASSESSOR:

Identify your role in the contract award or administration and the period of your involvement.

ROLE

PERIOD OF INVOLVEMENT

Contract Specialist/Contracting Officer Technical Project Lead/Project Officer

OTHERS

(Signature) (Date)

(Typed or Printed Name) (Organization Name)

(Phone Number)