S02_Attch_Past Performance Questionaire.docx
DOCX document 20 KB Posted
- Solicitation number
- 36C77025Q0122
About this file
The document is a Past Performance Questionnaire, a standardized form designed to capture detailed performance evaluations for contractors. The form is specifically related to Solicitation Number 36C77025Q0122 for Electronic Technician Staffing at the Department of Veterans Affairs Chelmsford CMOP location. The questionnaire provides a comprehensive rating scale from 0 (Neutral) to 5 (Exceptional) across five key performance dimensions: quality of product, timeliness, management effectiveness, customer satisfaction, and training/technical support.
The accompanying federal contract opportunity details indicate this is a Total SDVOSB (Service-Disabled Veteran-Owned Small Business) set-aside solicitation for temporary help services in the engineering/technical support category. The requirement is for a 6-month base period with one 6-month option period, covering Electronic Technician Staffing at 10 Industrial Avenue in Chelmsford, MA. The solicitation was issued on 3-20-25 with responses due by 3-27-25, and quotations are to be submitted via email to wade.cunningham@va.gov. The procurement will be conducted through the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 15.
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Attachment – Past Performance INSTRUCTIONS TO PRIME CONTRACTOR: (Contractor submitting proposal):
Complete the CONTRACTOR INFORMATION section. 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.
Company Name
Street Address
Point of Contact
City
Point of Contact Phone Number
State
E-Mail Address
Zip Code
Solicitation Number
Description of Work
INSTRUCTIONS TO REFERENCE CONTACT
Please complete the following pages as a past performance Reference Contract for the entity named above. Once completed, please return the form to: Larry Zaritz, larry.zaritz@va.gov.
RESPONDENT INFORMATION [completed by Reference Contact]
Government Agency or Company name
Street Address
POC Name
City
Phone Number
State
Fax Number
Zip Code
Contract Number
Prime or Subcontractor
Dollar Value
Period of Performance
Description of services provided
Location of services provided
Number of FTEE YOUR FIRM provided
PERFORMANCE INFORMATION: Choose the number on the scale of 0 (Neutral) to 5 (Exceptional) that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE AN EXPLANATION FOR THE OVERALL RATING in the Remarks section, below (text box will expand to whatever extent is necessary).
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| NEUTRAL |
| UNSATISFACTORY |
| MARGINAL |
| SATISFACTORY |
| GOOD |
| EXCEPTIONAL |
| No record of past performance or the record is incon-clusive. |
| Performance did not meet most contractual require-ments. 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 most contractual requirements. There were some minor problems and corrective actions taken by the contractor were satisfactory. |
| Performance met all contract requirements and exceeded some. There were a few minor problems, which the contractor resolved in a timely, effective manner. |
| Performance exceeded all contract requirements. There were no problems. |
| The Contractor … |
| 0 |
| 1 |
| 2 |
| 3 |
| 4 |
| 5 |
| 1. |
| Quality of Product to include workmanship and reliability |
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| 2. |
| Timeliness and Adherence to Project Schedules |
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| 3. |
| Management Effectiveness |
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| 4. |
| Customer Satisfaction |
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| 5. |
| Training and Technical Support |
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REMARKS (Please use as much space as is needed – the box will expand as you type).
I hereby certify that the information that I have reported above is accurate to the best of my knowledge.
Printed Name
E-mail address
Business Title
Signature
Date
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