PP Questionnaire.docx

Past Performance Information

OFFEROR INSTRUCTIONS: A separate record must be completed for each Past Performance Information and Survey; Offeror must directly send to the evaluator, requesting they complete and return as indicated on the attached Past Performance Survey, no later than, May 11, 2026 to david.alvarez4@va.gov . Further, Offeror must include a copy of each requested Past Performance Information page with proposal submission.

Name of Offeror being evaluated:

Address of Offeror:

Contract Details (i.e. Contract #/ Delivery or Task Order #, Title, Location, etc)

Evaluator’s Full Name:

Evaluator’s Position held or function in relation to project:

Evaluator’s Company/Organization Name, Address and Phone number:

Evaluator’s email address:

Please complete and return to: david.alvarez4@va.gov No Later Than: May 11, 2026

Past Performance Survey

Reference Instructions: The Department of Veterans Affairs is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Revolutionary FAR Overhaul (RFO) 15.301-1 prohibits the release of the names of the individuals providing reference information about the Offeror’s past performance. Survey should be completed by the evaluator and returned to david.alvarez4@va.gov, no later than the above date.

Please evaluate the Past Performance using only the following ratings without variation. If the rating is Marginal or Unacceptable, provide additional information in the appropriate block or in the remarks section of this form.

O = Outstanding = Performance greatly exceeded contract requirements

A = Above Average = Performance exceeded contract requirements

S = Satisfactory = Performance met contract requirements

M = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory.

U = Unacceptable = Performance was poor and/or did not satisfy contract requirements

NOTE: Do not use a color marking pen to circle the response. Best to use a ball point pen (Black or Blue) to circle your response.

Describe exactly what type of Home Oxygen service(s) were provided to your company/organization?

Length of the Service (Provide dates):

Q1. To what extent did the contractor comply with contract requirements?

O A S M U

Q2. How timely was the contractor’s performance?

O A S M U

Q3. How well did the contractor comply with the labor and safety standards?

O A S M U

Q4. Rate the effectiveness of the contractor’s management of the contract?

O A S M U

Q5. Rate the contractor’s handling of staff integrity issues.

O A S M U

Q6. Rate the contractor’s personnel management practices.

O A S M U

Q7. Quality Control: Rate the overall quality of contractor’s work.

O A S M U

Q8. How well did the contractor comply with the training requirements with respect to its employees?

O A S M U

Q9. What extent was contractor flexible in responding to changing needs?

O A S M U

Q10. To what extent was the contractor reliable?

O A S M U

Q11. To what extent was the Contractor responsive to technical directions?

O A S M U

Q12. Have any cure notices, show cause letters, suspension of payment, or termination been issued? If yes, explain on the following page.

Yes No

Q13. Would you award another contract to this contractor? If no, explain on the following page.

Yes No

Q14. Was the customer satisfied with the service provided? If no, explain on the following page.

Yes No

Q15. To what extent did contractor notify you of problems of potential issues?

O A S M U

Past Performance Survey – Remarks Section

Evaluator’s Additional Remarks regarding services:

Signature of Evaluator: Date of Evaluation:

Print Name of Evaluator:

Please email scanned copy directly to david.alvarez4@va.gov Do NOT return survey to the company you are evaluating