Past Performance Questionnaire.pdf

Department of Veterans Affairs Network Contracting Office 5

Washington DC VAMC 50 Irving Street, N.W., Washington DC 20422

Past Performance Questionnaire for: 688-CSI-013 Cardiac Cath Lab Replacement Room 4A124 at the Washington DC VAMC (Construction)

Instruction to Interested Party:

Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes).

Save the document. Send an electronic or hard copy print of the form to each of your reference contacts, asking them to please complete the form and return to you in a timely manner.

Company Name Street Address

Point of Contact (POC) City

POC Phone Number State

Reference Project Title Zip Code

Contract Period of Performance

Email

Contract Number Contract Dollar Value

Description of Work

Role of Contractor on referenced contract (check box)

Prime Contractor Sub-Contractor Key Personnel

Washington DC VAMC

Instructions to Reference Contract:

The contractor named above is an interested party for a United States Department of Veterans Affairs solicitation, and has sent this form to you as a past performance reference contact. Please complete the following pages in full (all areas shaded in light yellow, below). Once completed, please return this form to

[insert name / email address] ______________________________ by no later than [insert date and time]

RESPONDENT INFORMATION [completed by Reference Contact]

Company Name Street Address

Point of Contact (POC) City

POC Phone Number State

POC Email Zip Code

Washington DC VAMC

Performance Information:

Choose the number on the scale of 0 (Neutral) to 5 (Exceptional) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE AN EXPLANATION FOR THE OVERALL RATING in the Remarks section, below.

0 1 2 3 4 5 Neutral Unacceptable Marginal Acceptable Very Good Outstanding

No record of past performance, or not applicable or the record is inconclusive.

Performance did not meet most contractual requirements.

There were serious problems and the contractor’s corrective actions were ineffective.

Performance did not meet some contractual requirements.

There were problems, some of a serious nature, for which corrective action was only marginally effective.

Performance met most contractual requirements.

There were some minor problems and corrective actions taken by the contractor were satisfactory.

Performance met all contract requirements and exceeded some to the government’s benefit. There were a few minor problems, which the contractor resolved in a timely, effective manner.

Performance exceeded all contract requirements. There were no problems.

Quality – Management and Workmanship The Contractor… 0 1 2 3 4 5 1 Provided experienced managers and supervisors with the technical and administrative abilities needed to meet contract requirements.

2 Demonstrated ability to hire, maintain, and replace, if necessary, qualified construction personnel during the contract period.

3 Provided and followed approved quality control plan and/or inspection procedures to meet contract requirements.

4 Corrected deficiencies in timely manner and pursuant to their quality control procedures.

5 Submittals clearly identified the proposed item IAW the specifications and drawings.

6 Suggested alternative approaches to problems.

7 Contractor provided timely notices of possible delays / schedule revisions.

REMARKS:

Washington DC VAMC

8 Timeliness in submitting submittals and reports and responding to agency inquiries, RFP's, etc.

9 Developed realistic and met approved progress schedules.

Business Practices / Customer Relationship and Ability to Perform

The Contractor… 0 1 2 3 4 5 10 Displayed initiative to solve problems.

11 How well did the contractor work independent of Government guidance, oversight, and assistance?

12 Subcontractors / tradesmen were adequately managed and coordinated. Explain any subcontracting issues (positive or negative) that impacted the performance of your contract(s).

Washington DC VAMC

13 For contract changes, contractor provided timely and realistic change order proposals.

Compliance and Safety The Contractor… 0 1 2 3 4 5 14 Reports (i.e., daily, test, logs) / records were submitted completely and accurately satisfy the requirement.

15 Applicable to Federal Contracts –Contractor complied with applicable Federal Laws and Regulations such as Construction Wage Rate Requirements – timely payrolls and compliance;

Drug-Free Workplace; Environmental Regulations and Use of Recovered Materials; Executive Order 13101 Greening the Government.

16 Contractor’s safety program was in compliance with federal regulations. Contractor implemented and followed their safety plan and ran a “safe jobsite”.

Infection Control

17 Contractor had an Infection Control Process in place and complied with agency Infection Control Requirements.

Overall Customer Satisfaction

18 Demonstrated reasonableness in modifications cost proposal.

19 Was the contractor ever issued a cure or show cause notice under the referenced contract? If yes, explain outcome in “remarks.”

Yes No

20 Would you award another contract to this contractor? If not, please explain in “remarks.”

Yes No

Washington DC VAMC

OVERALL PERFORMANCE RATING

Remarks:

I hereby certify that the information that I have reported above is accurate to the best of my knowledge.

Printed Name Signature Date

Business Title / Company Name E-mail address