Past Performance Questionnaire_Surgical.pdf

ATTACHMENT 1

PAST PERFORMANCE QUESTIONNAIRE COVER SHEET

PAST PERFORMANCE QUESTIONNAIRE

SOLICITATION# 36C24823FQ0644

SURGICAL INSTRUMENT REPAIR

REQUIREMENT

The entire questionnaire should be forwarded to your previous customers (at least 3) for completion and customers shall directly return the cover sheet and questionnaire to Keila President at e- mail address: keila.president@va.gov It is your responsibility to ensure correct and verifiable point of contact information. Information that is incorrect or unverifiable may lead to a lower past performance rating.

(Offeror Fill-In Below)

1. Offeror Name (Name of Organization/Firm being Evaluated):

2. Name of Organization/Firm Providing Reference:

3. Address of Organization/Firm Providing Reference:

4. Contract Number:

5. Project Description:

6. Contract/Task Order Amount:

7. Performance Period:

8. Evaluator’s Point of Contact Information:

Name and Title:

Phone Number:

Fax

E-Mail Address:

PAST PERFORMANCE QUESTIONNAIRE

SOLICITATION RFP #36C24823Q0837

ADJECTIVAL RATINGS AND DEFINITIONS TO BE USED TO BEST REFLECT YOUR

EVALUATION OF THE CONTRACTOR’S PERFORMANCE

E (EXCELLENT) Performance meets contractual requirements and exceeds expectations. The contractual performance of the element assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective. (High Confidence).

G (GOOD) Performance meets contractual requirements and exceeds some requirements. The contractual performance of the element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective. (Significant Confidence).

S (SATISFACTORY) Performance meets contractual requirements. The contractual performance of the elements contains some minor problems for which corrective action taken by the contractor is satisfactory.

(Confidence).

M (MARGINAL) Performance does not meet some contractual requirements. The contractual performance of the element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented. (Little Confidence).

P (POOR) Performance does not meet most contractual requirements and recovery is no likely in a timely manner. The contractual performance of the element contains serious problems for which the contractor’s corrective actions appear or were ineffective. (No confidence).

NR (NO RATING) No relevant past performance record is identifiable upon which to base a meaningful performance risk prediction. A search was unable to identify any relevant past performance information for the contractor or their key personnel. (This is neither a negative or positive assessment).

EVALUATOR: PLEASE CIRCLE THE ADJECTIVAL RATING WHICH BEST

REFLECTS YOUR EVALUATION OF THE CONTRACTOR’S PERFORMANCE

Was this a competitive contract? YES NO Role of the contractor Prime Contractor

Subcontractor or

Ability to meet quality standards specified for technical performance

E G S M P NR

Compliance with contractual terms and conditions

E G S M P NR

Quality/integrity of technical data/report preparation efforts.

E G S M P NR

Adequacy/effectiveness of quality control program and adherence to contract quality assurance requirement.

E G S M P NR

Effectiveness of overall contract management (including ability to effectively lead, manage, and control the project.)

E

G

S

M

P

NR

Effectiveness of on-site management and control of multidiscipline construction categories, including management of subcontractors.

E G S M P NR

Contractor was reasonable and cooperative in dealing with staff (including the ability to successfully resolve disagreements/disputes;

responsiveness to administrative reports).

E G S M P NR

Timeliness/effectiveness of contract problem resolution without extensive customer guidance.

E G S M P NR

Ability to successfully respond to emergency situations.

E G S M P NR

Effectiveness of material management. E G S M P NR Contractor proposed innovative alternative methods that reduced cost, improved maintainability or other factors that benefited the client.

E G S M P NR

Contractor Safety Record. E G S M P NR Contractor responsiveness to safety issues. E G S M P NR Contractor’s timeliness, completeness, and accuracy in submitting invoices.

E G S M P NR

Ability to hire and retain a qualified workforce to this effort.

E G S M P NR

If this was a government contract has the contract been terminated for default or Convenience? Indicate if show cause or cure notices were issued or any default action in the comment section below.

Have there been any indications that the contractor has had any financial problem?

COMMENTS:

Evaluator’s Point of Contact Information:

Signature and Title:

Phone

Email Address: