Attachment 5: Past Performance Questionnaire

PAST PERFORMANCE QUESTIONNAIRE (PPQ)

SECTION 1

CONTRACT INFORMATION – Contractor to complete #1-3

1. CONTRACTOR INFORMATION

NAME OF OFFEROR BEING EVALUATED: Click or tap here to enter text. ADDRESS: Click or tap here to enter text.
POINT OF CONTACT: Click or tap here to enter text.
CONTACT PHONE NUMBER: Click or tap here to enter text.
CONTACT EMAIL ADDRESS: Click or tap here to enter text. WORK PERFOMED AS: Click or tap here to enter text.
PERCENT OF PROJECT WORK PERFORMED: Click or tap here to enter text. IF SUBCONTRACTOR, WHO WAS THE PRIME? Click or tap here to enter text.

2. CONTRACT INFORMATION

CONTRACT TITLE: Click or tap here to enter text.
CONTRACT NUMBER AND DO/TO NUMBER: Click or tap here to enter text. CONTRACT TYPE: Choose an item.
if other:
CONTRACT LOCATION: Click or tap here to enter text.
AWARD DATE: Click or tap to enter a date.
ORIGINAL CONTRACT ACCCEPTANCE (construction accepted) Date: Click or tap to enter a date. ACTUAL CONTRACT ACCEPTANCE: Click or tap to enter a date. EXPLAIN DIFFERENCES: Click or tap here to enter text.
ORIGINAL CONTRACT PRICE (all costs - design/installation/financing): Click or tap here to enter text. FINAL CONTRACT PRICE (including modifications, if applicable): Click or tap here to enter text. EXPLAIN DIFFERENCES: Click or tap here to enter text.

3. PROJECT DESCRIPTION

SCOPE INCLUDED IN PROJECT: Click or tap here to enter text.

HOW IS THIS PROJECT RELEVANT TO PROJECT OF SUBMISSION? Click or tap here to enter text.

SECTION 2

EVALUATOR INFORMATION – Client to complete

Veterans Health Administration (VHA) Regional Procurement Office-West (RPOW) Network Contracting Office 20 (NCO 20) is considering the Offeror identified above for award of Project # 668-24-106, Renovate the Community Living Center (CLC) East Wing and Courtyard, at the Mann-Grandstaff VA Medical Center, Spokane, WA 99205. Your comments would be appreciated regarding this firm’s past performance. The intent of this form is to determine the company’s ability to responsibly perform the work as described in the solicitation. Please verify the accuracy of the information in Section 1 and complete the questionnaire as thoroughly as possible. NCO 20 may contact you in order to obtain any additional information regarding a contract award.

EVALUATOR INFORMATION

NAME OF EVALUATOR: Click or tap here to enter text.
POSITION: Click or tap here to enter text.
ADDRESS: Click or tap here to enter text.
PHONE: Click or tap here to enter text.