PPQ Form.pdf

PERFORMANCE QUESTIONAIRE

36C26326R0059, Project: 636A6-26-201, Patient Ceiling Lifts

Install & Testing

INSTRUCTIONS TO CONTRACTOR

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 submit it according to the instructions, below.

INSTRUCTIONS TO REFERENCE CONTACT

The contractor named below is submitting an offer for a United States Department of Veterans Affairs contract requirement, and has sent this form to you, in your role as a past performance reference contact. Please complete this form in full (all areas shaded in light yellow, below). Once completed, please send the form to the Contracting Officer via email at derek.fore@va.gov.

Please return the completed form NLT June 18, 2026 at 10:00 am CT.

GENERAL INFORMATION [completed by Contractor]

Contractor Company Name Street Address

Contractor Point of Contact Name City

Point of Contact Phone Number State

Reference Project Title Zip Code

Contract Period of Performance (start to finish): Email

Contract Number Contract Dollar Value

Description of Work

Role of Contractor on This Project (check appropriate box) ☐ Prime Contractor ☐ Sub‐contractor ☐ Key Personnel

36C26324R0087, Project: 636-23-301, D/B Improve Stormwater

Detention

RESPONDENT INFORMATION [completed by Reference Contact]

Company Name Street Address

POC Name City

Phone Number State

Fax Number Zip Code

Email

PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 5 that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 1 OR 2 in the Remarks section, below (text box will expand to whatever extent is necessary).

1 2 3 4 5

UNSATISFACTORY MARGINAL SATISFACTORY VERY GOOD EXCEPTIONAL

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 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 met all contract requirements and exceeded many to the government’s benefit. Problems, if any, were negligible and were resolved in a timely, highly effective manner.

The Contractor … 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 personnel during the contract period.

3. Delegated authority to project managers and supervisors commensurate with contract requirements.

4. Home office participated in solving significant local problems. ☐ ☐ ☐ ☐ ☐

5. Followed approved quality control plan. ☐ ☐ ☐ ☐ ☐

6. Provided effective quality control and/or inspection procedures to meet contract requirements.

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

8. Provided timely resolution of contract discrepancies ☐ ☐ ☐ ☐ ☐

9. Identified problems as they occurred. ☐ ☐ ☐ ☐ ☐

Suggested alternative approaches to problems. ☐ ☐ ☐ ☐ ☐

Displayed initiative to solve problems. ☐ ☐ ☐ ☐ ☐

36C26324R0087, Project: 636-23-301, D/B Improve Stormwater

Detention

Developed realistic progress schedules. ☐ ☐ ☐ ☐ ☐

Met established project schedules. ☐ ☐ ☐ ☐ ☐

Provided timely resolution of warranty defects. ☐ ☐ ☐ ☐ ☐

Was responsive to contract changes. ☐ ☐ ☐ ☐ ☐

Provided adequate project supervision. ☐ ☐ ☐ ☐ ☐

Obtained consent of surety for increases in bonding as work‐in‐progress increased. ☐ ☐ ☐ ☐ ☐

Paid subcontractors/suppliers in a timely manner. ☐ ☐ ☐ ☐ ☐

Provided accurate and complete line item cost proposals including all aspects of work required for each task.

Cooperated with Government personnel after award. ☐ ☐ ☐ ☐ ☐

How would you rate the contractor's overall performance? ☐ ☐ ☐ ☐ ☐

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

YES

NO

23 Would you award another contract to this contractor? If not, please explain in

“remarks.”

YES

NO

24 To the best of your knowledge, is the contractor rated in CPARS? ☐

YES

NO

REMARKS (Please use as much space as is needed – the box will expand as you type).

Name of Person Completing Form Signature