ATTACHMENT F PAST PERFORMANCE QUESTIONNAIRE NX EQ Ultrasonic Aspirator System Tissue Ablation

Attachment F
Past Performance Questionnaire
Offerors: Please Send to Each Reference Cited in Submitted Proposal (Maximum of 3 References from Past Three Years)

DEPARTMENT OF VETERANS AFFAIRS (VA)

ENTERPRISE PROCUREMENT OFFICE (EPO)

PAST PERFORMANCE QUESTIONNAIRE

E-MAIL completed form to: [email protected], ensuring that the email subject line includes “36C10X27R0005”

VA EPO is currently in the process of awarding a contract for the solicitation described above. The Offeror identified below has provided your organization’s name as a reference under the contract described below:

Offeror Name:
(Insert Offeror’s Name Here)
Contract Number:
(Insert Applicable Contract Number Here)

Please rate the Offeror in each of the categories on this questionnaire. See “Rating Guidelines” section for detailed description of categories and ratings. There is room for comments where you deem remarks would be helpful to our evaluation (see ‘Comment from Reference’ under “Offeror Evaluation.” Please note that the past performance evaluators for this solicitation may contact you for further details in making a fair assessment of this Offeror’s past performance. Thank you for your organization’s assistance in fairly evaluating Offeror proposals for this solicitation. Name of Reference:
(Reference Complete These Sections)
Title of Reference:

Phone Number:

E-Mail Address:

Name of Organization:

Contract Period of Performance (Month/Day/Year Begin and End):

Total Contract Value (Base and All Option Years):

Options Exercised on Contract (Yes/No)?

Brief Description of Services/Commodity Provided by Offeror:

Show Cause Order Issued on Contract (Yes/No)?

Stop Work Order Issued on Contract (Yes/No)?

Termination for Convenience, Cause, or Default Issued on Contract (Yes/No)?

Rating Guidelines:

Rating
Quality of Service
Cost Control
Timeliness of Performance
Business Relations
1: Unsatisfactory
Offeror is not in compliance and has jeopardized achievement of contract objectives Offeror is unable to manage costs effectively
Offeror delays have jeopardized performance
Responses to inquiries and issues are not effective
2: Satisfactory
Minor inefficiencies and errors have been identified
Offeror is usually effective in managing costs
Offeror is usually effective in meeting milestones and delivery schedule Responses to inquiries and issues is usually effective
3: Excellent
Offeror is in compliance with contract requirements and delivers quality services