Attachment 5: Past Performance Questionnaire

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, 02 November 2026 at 10:00 a.m. CST to [email protected] and [email protected]. Further, Offeror must either include a copy of each requested Past Performance Information page or provide the same information on a separate document 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: [email protected] and [email protected] No Later Than: 02 November 2026, at 10:00 a.m. CST

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 Federal Acquisition Regulation (FAR) 15.506 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 [email protected], 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 ballpoint pen (Black or Blue) or electronic means to circle your response.

Describe the supplies/products provided to your company/organization?

Length of Contract (Provide dates):

Rate the following questions if the company provided flat bronze markers or similar products/supplies. Provide information/comments in the Remarks Section below.