Past Performance Questionnaire.pdf

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VA Portland Healthcare System Floor Care Tile and Grout Antimicrobial Sealant
Solicitation number
36C26025Q0850
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This document is a Past Performance Questionnaire used by the Veterans Healthcare Administration (VHA) to collect performance feedback on a contractor. The form provides a structured evaluation matrix with nine assessment categories, including quality of product/service, schedule, cost control, business relations, management of key personnel, reliability, customer support, overall performance, and space for additional areas of assessment. The form requires detailed information about the contractor, such as contract type, period of performance, contract award and completion dates, and current contract dollar value. Respondents are instructed to rate the contractor's performance across each category using a scale from Unsatisfactory to Exceptional, with an option for Not Applicable (N/A). The completed questionnaire may be used in an award decision process, and respondents are directed to submit their feedback directly to a specified contact by a designated date and time.

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Past Performance Questionnaire

CONTRACT TYPE (if applicable):

CONTRACT COMPLETION DATE:

1. NAME OF FIRM/AGENCY PROVIDING FEEDBACK:

CONTRACTOR NAME:

PERIOD OF PERFORMANCE:

CONTRACT AWARD DATE:

AWARDED VALUE: CURRENT CONTRACT DOLLAR VALUE:

2. NAME OF ASSESSING OFFICIAL:

EMAIL: PHONE NUMBER:

ASSOCIATION WITH FIRM BEING RATED (including role):

CONTRACT OR ORDER NUMBER (if applicable):

3. ASSESS THE FOLLOWING AREAS: (Check the appropriate box for each assessment category)

4 TASKS PERFORMED AND ADDITIONAL COMMENTS:

Assessment Categories Unsatisfactory Marginal Satisfactory Very Good Exceptional N/A

a. QUALITY OF PRODUCT OR SERVICE

b. SCHEDULE

c. COST CONTROL

d. BUSINESS RELATIONS

e. MANAGEMENT OF KEY PERSONNEL

f. RELIABILITY

g. CUSTOMER SUPPORT

h. OVERALL PERFORMANCE

i. OTHER AREAS:

(1)

(2)

Responses may used in an award decision by Veterans Healthcare Administration (VHA). Please submit the response directly to (FILL IN CS INFO) by (FILL IN DATE AND TIME). Do not send to the Contractor requesting the Questionnaire. We greatly thank you for your assistance!

VHABOICarriD Highlight

VHABOICarriD Highlight

1 NAME OF FIRMAGENCY PROVIDING FEEDBACK:
PERIOD OF PERFORMANCE:
CONTRACT TYPE if applicable:
CONTRACT AWARD DATE:
CONTRACT COMPLETION DATE:
AWARDED VALUE:
CURRENT CONTRACT DOLLAR VALUE:
2 NAME OF ASSESSING OFFICIAL:
EMAIL:
PHONE NUMBER:
ASSOCIATION WITH FIRM BEING RATED including role:
CONTRACT OR ORDER NUMBER if applicable:
Assessment Categories:
Unsatisfactorya QUALITY OF PRODUCT OR SERVICE:
Marginala QUALITY OF PRODUCT OR SERVICE:
Satisfactorya QUALITY OF PRODUCT OR SERVICE:
Very Gooda QUALITY OF PRODUCT OR SERVICE:
Exceptionala QUALITY OF PRODUCT OR SERVICE:
NAa QUALITY OF PRODUCT OR SERVICE:
Unsatisfactoryb SCHEDULE:
Marginalb SCHEDULE:
Satisfactoryb SCHEDULE:
Very Goodb SCHEDULE:
Exceptionalb SCHEDULE:
NAb SCHEDULE:
Unsatisfactoryc COST CONTROL:
Marginalc COST CONTROL:
Satisfactoryc COST CONTROL:
Very Goodc COST CONTROL:
Exceptionalc COST CONTROL:
NAc COST CONTROL:
Unsatisfactoryd BUSINESS RELATIONS:
Marginald BUSINESS RELATIONS:
Satisfactoryd BUSINESS RELATIONS:
Very Goodd BUSINESS RELATIONS:
Exceptionald BUSINESS RELATIONS:
NAd BUSINESS RELATIONS:
Unsatisfactorye MANAGEMENT OF KEY PERSONNEL:
Marginale MANAGEMENT OF KEY PERSONNEL:
Satisfactorye MANAGEMENT OF KEY PERSONNEL:
Very Goode MANAGEMENT OF KEY PERSONNEL:
Exceptionale MANAGEMENT OF KEY PERSONNEL:
NAe MANAGEMENT OF KEY PERSONNEL:
Unsatisfactoryf RELIABILITY:
Marginalf RELIABILITY:
Satisfactoryf RELIABILITY:
Very Goodf RELIABILITY:
Exceptionalf RELIABILITY:
NAf RELIABILITY:
Unsatisfactoryg CUSTOMER SUPPORT:
Marginalg CUSTOMER SUPPORT:
Satisfactoryg CUSTOMER SUPPORT:
Very Goodg CUSTOMER SUPPORT:
Exceptionalg CUSTOMER SUPPORT:
NAg CUSTOMER SUPPORT:
Unsatisfactoryh OVERALL PERFORMANCE:
Marginalh OVERALL PERFORMANCE:
Satisfactoryh OVERALL PERFORMANCE:
Very Goodh OVERALL PERFORMANCE:
Exceptionalh OVERALL PERFORMANCE:
NAh OVERALL PERFORMANCE:
Unsatisfactoryi OTHER AREAS:
Marginali OTHER AREAS:
Satisfactoryi OTHER AREAS:
Very Goodi OTHER AREAS:
Exceptionali OTHER AREAS:
NAi OTHER AREAS:
1:
Unsatisfactory1:
Marginal1:
Satisfactory1:
Very Good1:
Exceptional1:
NA1:
2:
Unsatisfactory2:
Marginal2:
Satisfactory2:
Very Good2:
Exceptional2:
NA2:
4 ADDITIONAL COMMENTS:
CONTRACTOR NAME:

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