Exhibit B Past and Present Performance Qestionnaire

FOR OFFICIAL USE ONLY

Modernize 6N Inpatient Restrooms (Swing for 3N)

EXHIBIT B

PAST PERFORMANCE QUESTIONNAIRE

INSTRUCTIONS TO CONTRACTOR

Complete the CONTRACTOR INFORMATION section, below (type answers into light blue shaded boxes). 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.

INSTRUCTIONS TO REFERENCE CONTACT

The contractor named below is submitting an offer for a United States Department of Veterans Affairs contract requirement, and has sent this form to you, in your role as a past performance reference contact. Please complete this form in full (all areas shaded in light yellow, below). Once completed, please send the form to the Contract Specialist via postal mail or email, directly to:
Department of Veterans Affairs NCO 16 Contracting Office ATTN: Andrea Payton, Contract Specialist REF: 36C25626R0108 1800 Buckner Street, Suite C200, RM 23
Shreveport, LA 71101 Email Address: [email protected] Please return the completed form no later than the time set for receipt of proposals. If you have any questions, please contact Ms. Payton via email. Thank you for your assistance in this matter.
GENERAL INFORMATION [completed by Contractor]
Contractor Company
Name

Street
Address

Contractor Point of
Contact Name

City

Point of Contact Phone
Number

State

Reference Project Title
Contract Period of
Performance (start to
finish):

Zip Code
Email
Contract
Dollar Value

Contract Number
Description of Work
Role of Contractor on
This Project (check
appropriate box)

☐ Prime Contractor ☐ Sub-contractor ☐ Key Personnel

Source Selection Information - See FAR 2.101 and 3.104

36C25626R0108 | Project No. 667-27-130

FOR OFFICIAL USE ONLY

Modernize 6N Inpatient Restrooms (Swing for 3N)
RESPONDENT INFORMATION [completed by Reference Contact] Street
Address
City
State
Zip Code

Company Name
POC Name
Phone Number
Fax Number
Email

PERFORMANCE INFORMATION: Choose the number on the scale of 1 to 6 that most accurately describes the contractor’s performance or situation. PLEASE PROVIDE A NARRATIVE EXPLANATION FOR ANY RATINGS OF 1 OR 2 in the Remarks section, below (text box will expand to whatever extent is necessary).

UNSATISFACTORY

Performance did not
meet most
contractual
requirements. There
were serious
problems and the
contractor’s
corrective actions
were ineffective.