PPQ-Template.pdf

PAST PERFORMANCE QUESTIONNAIRE

SUBJECT: Past Performance Questionnaire for Project 626A4-20-104, Upgrade Nurse Call System for the Tennessee Valley Healthcare System at the Nashville and Murfreesboro VA Medical Centers.

PAST PERFORMANCE INSTRUCTIONS

The NCO 9 Network Contracting Activity has issued a solicitation for Project 626A4-20-104, Upgrade Nurse Call System for the Tennessee Valley Healthcare System at the Nashville and Murfreesboro VA Medical Centers.

Past performance information will be used to evaluate proposals received. Section A is to be completed by the Offeror. Section A of the enclosed questionnaire lists the contractor who has identified your office as a source to evaluate their past performance. Section A also authorizes the release of this information to NCO 9 Network Contracting Activity.

The Offeror must provide this entire document to each of its assessors. The Assessor shall only submit past performance questionnaires directly to the Contracting Officers – Craig Ziegemeier by email at craig.ziegemeier@va.gov and Teresa Rogofsky by email at teresa.rogofsky@va.gov.

Section B in its entirety is to be completed by the assessor(s). An individual assessor knowledgeable of the contractor’s quality of supplies and services rendered is requested to verify, complete the questionnaire, and submit it to the contracting office. If evaluating more than one contract for the same contractor, use a separate questionnaire for each contract being evaluated.

Because this information is critical to the evaluation process, your time and effort in providing your assessment are greatly appreciated. The questionnaire should be completed as soon as possible but not later than January 13, 2022 at 12:00 PM CT. The assessor is requested to send electronically to craig.ziegemeier@va.gov and teresa.rogofsky@va.gov. Assessor: Please do not send this information to the Offeror being evaluated.

Thank you in advance for your cooperation and expeditious response to this request.

Procurement Sensitive Do Not Disclose --- See FAR Subparts 2.101 and 3.104-4 FOR OFFICIAL USE ONLY mailto:craig.zeigemeier@va.gov mailto:dewayne.knowles@va.gov mailto:craig.zeigemeier@va.gov mailto:dewayne.knowles@va.gov

Procurement Sensitive Do Not Disclose --- See FAR Subparts 2.101 and 3.104-4 FOR OFFICIAL USE ONLY

PAST PERFORMANCE QUESTIONNAIRE

SECTION A: Contractor Information (to be completed by the contractor for who past performance information is being collected, before forwarding to assessors)

Solicitation Number 36C24921R0141 Project/Requirement Project 626A4-20-104 Customer/Agency Tennessee Valley Healthcare System

1. Prospective Government Contractor’s __________________________________________________ Name and Address __________________________________________________

2. Contractor Point of Contact: __________________________________________________

3. Phone Number (with area code): __________________________________________________

4. Assessor Contract Award Number: __________________________________________________

5. Description of Services: __________________________________________________

6. Contract Award Date: _______________ Contract Amount: Initial ___________ Final___________

7. Period of Performance: __________________________________________________

ASSESSOR INFORMATION:

Assessor Name Title Phone Number/Email Address

Authorization is hereby granted to provide the information requested in this questionnaire to the NCO 9 Network Contracting Activity, Murfreesboro, Tennessee.

Signature

Name and Title of Authorizing Official Date

SECTION B: Assessor's Information (to be completed by assessors).

RATING SCALE Definitions

Past Performance Evaluation Ratings Rating Description ACCEPTABLE Based on the Offeror’s performance record, the

Government has a reasonable expectation that the offeror will successfully perform the required effort, or the Offeror’s performance record is unknown. (See note below.)

UNACCEPTABLE Based on the Offeror’s performance record, the Government has no reasonable expectation that the offeror will be able to successfully perform the required effort.

The questions on the survey below shall be rated in accordance with the definitions provided in the Rating Scale. Any unsatisfactory or marginal rating shall be supplemented with an explanation in the space provided.

QUALITY OF SERVICE

1. Rate the contractor’s compliance with contractual requirements.

ACCEPTABLE_______ UNACCEPTABLE_______

2. Overall rating of contractor quality of service.

ACCEPTABLE_______ UNACCEPTABLE_______

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

SCHEDULE

3. Delivery of service was within the required time specified by contract requirements.

ACCEPTABLE_______ UNACCEPTABLE_______

4. Rate the contractor’s ability to control cost and submit invoices. Are invoices complete, accurate, and timely?

ACCEPTABLE_______ UNACCEPTABLE_______

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

BUSINESS RELATIONS

5. Overall rating of contractor’s business practices (e.g. maintaining a positive working relationship, business ethics, timely and effective resolution of any problems, etc.)

ACCEPTABLE_______ UNACCEPTABLE_______

6. Rate the working relationship between contractor’s management, and your company (i.e. contractor’s history of reasonable and cooperative behavior, commitment to customer satisfaction; concern for the interest of the customer).

ACCEPTABLE_______ UNACCEPTABLE_______

7. Rate the contractor’s ability to submit required reports and/or invoices on time.

ACCEPTABLE_______ UNACCEPTABLE_______

8. Rate the contractor’s responsiveness to customer complaint resolution.

ACCEPTABLE_______ UNACCEPTABLE_______

9. Overall rating of contractor’s business relations.

ACCEPTABLE_______ UNACCEPTABLE_______

PLEASE PROVIDE RATIONALE FOR ASSIGNED RATING:

Would you award another contract to this contractor?

__________ Would award to this contractor again.

__________ Would not award to this contractor again.

PLEASE PROVIDE RATIONALE:

Overall rating of contractor’s performance (quality, schedule, business relations,) on the contract being assessed.

ACCEPTABLE UNACCEPTABLE

VII. General Comments:

ASSESSOR:

Identify your role in the contract award or administration and the period of your involvement.

ROLE

TIME PERIOD OF INVOLVEMENT

Contract Specialist/Contracting Officer Technical Project Lead/Project Officer Other:

(Signature) (Date)

(Typed or Printed Name) (Organization Name)

(Phone Number)