Past Performance Questionnaire.pdf
PDF 155 KB Posted
- Solicitation number
- 36C24526Q0254
About this file
This is a Past Performance Questionnaire for RFQ No. 36C24526Q0254 issued by the Department of Veterans Affairs for Magnetic Resonance Imaging services. The questionnaire is a template designed to collect reference information from parties who have previously contracted with an offeror to assess their past performance on similar work.
The questionnaire requests reference information including the responding company's name, contact person, email, contract number, period of performance, and scope of services. Respondents are instructed to rate the offeror's performance across two primary categories: Quality of Performance (covering conformance to contract specifications, quality of workmanship including technical, professional, and safety standards, and timely submittal of reports and documentation) and Management Performance if applicable (assessing management responsiveness, personnel management, and conflict/issue resolution). For each criterion, respondents select one of three ratings: Satisfactory (performance meets all contractual requirements with only minor issues and effective corrective actions), Unsatisfactory (performance does not meet requirements with significant problems and ineffective corrective actions), or Neutral (unable to provide meaningful assessment). The questionnaire includes space for general comments and an assessor signature. All information provided is treated as confidential evaluation information exempt from FOIA disclosure, with respondent names protected. Completed questionnaires should be emailed to jameel.gordon@va.gov.
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Other files
| File | Type | Posted |
|---|---|---|
| Supplemental instructions.pdf | ||
| Solicitation No. 36C24526Q0254.pdf |
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Text version
Past Performance Questionnaire - RFQ No. 36C24526Q0254
The Department of Veterans Affairs is evaluating a quote from [Offeror’s name here], hereafter referred to as “Offeror,” for Magnetic Resonance Imaging services. Offeror has provided this questionnaire to you so that we may ask you questions regarding Offeror’s past performance on a similar contract between your company and Offeror.
Any information you provide in this questionnaire is considered Evaluation Information and is prohibited from disclosure and exempt from release under the Freedom of Information Act; as such, the Department of Veterans affairs will not release your name or the names of other individuals providing reference information about Offeror’s past performance.
Instructions: Provide an assessment of the Offeror’s past performance by checking the box with one of the following rating options. You are encouraged to write comments as often as you’d like.
Rating Options:
Satisfactory—Offeror’s performance meets (or met) all contractual requirements and performance was accomplished with minor issues or concerns, for which Offeror’s corrective actions were effective.
Unsatisfactory—Offeror’s performance does not meet (or did not meet) contractual requirements and performance was accomplished with significant problems, issues or concerns, for which Offeror’s corrective actions were ineffective.
Neutral—Unable to provide a meaningful assessment.
Please email your completed questionnaire to jameel.gordon@va.gov when you’re finished.
Performance Assessment
1. Reference Information
Your Company’s Name: ________________________________________________________
Your Name: ______________________ Email: ____________________________
Contract Number (if Government): ________________________________________________
Period of Performance: Start Date: _________________ End Date: ___________________
Scope of Services (e.g., types of services provided, types of sterilization equipment serviced, contract dollar value, etc.):
a. Quality of performance
Satisfactory Unsatisfactory Neutral
Conformance of contract specifications
Quality of workmanship (technical, professional, safety, and the like)
Timely submittal of all reports and documentation
b. Management performance (if applicable)
Satisfactory Unsatisfactory Neutral
Management responsiveness (timeliness, reliability, cooperation, etc.)
Management of personnel (hiring, training, retaining, replacing, etc.)
Management of conflicts or issues (reactive, provides good solutions, flexible to changing needs, etc.)
c. General comments:
Assessor’s Signature: __________________________
THANK YOU FOR YOUR SUPPORT AND PARTICIPATION!
File details come from the government source that posted it. Updated .