G-004 Solicitation for Homeless Care for Homeless Veterans (HCHV) Services for Louis Stokes Cleveland VA Medical Center

Page 1 of 2 PAST PERFORMANCE QUESTIONNAIRE ________________________ REQUEST FOR QUOTATION (RFQ) 36C25026Q0466 HCHV Services Louis Stokes Cleveland VA Medical Center MESSAGE TO THE EVALUATOR: Your assistance is requested by Angela Higgins, Contracting Officer to assist with establishing the performance history for the Company (Offeror) named below. In efforts to expedite receipt of the requested information, the Contracting Officer respectfully requests that you do not mail hard copies. Instead, please e-mail the completed past performance questionnaire(s) to: angela.higgins@va.gov. If enough space is not provided, then please attach additional information to this questionnaire. Please provide the survey back on or before August 3, 2026. . 1. Name of Offeror /Agency: Contract Number: Title/Description of Contract: Period of Performance: Based upon the definitions below, indicate your assessment of the offeror’s performance. Your assessment should consider the offeror’s performance in accordance with the contractual requirements. Please include the period of performance and contract value: 2. Brief description of scope of work: . EVALUATION: Please rate the offeror using the guide and the pull-down menus in the evaluation table below. Explanatory narratives for as many responses as possible would be appreciated. These narratives need not be lengthy, just detailed. Attach additional pages if more space is needed. ASSESSMENT DEFINITION Outstanding (O) The Offeror’s performance met contractual requirements and exceeded many requirements to the Client’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the offeror were highly effective. Above Average (A) The Offeror’s performance met contractual requirements and exceeded some requirements to the Client’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the offeror were effective. Satisfactory (S) The Offeror’s performance met contractual requirements. The contractual performance contained some minor problems for which corrective actions taken by the offeror were satisfactory. Unacceptable (U) Performance did not meet contractual requirements. The contractual performance reflected a serious problem for which the offeror has yet to identify corrective actions or the offeror’s proposed actions appear only marginally effective or were not fully implemented. -- 1 of 2 -- Page 2 of 2 Completed scheduled services in a timely manner per the Performance Work Statement (PWS). Choose an item. Compliance with contractual Terms and Conditions. Choose an item. Provided experienced personnel with sufficient technical and administrative abilities needed to meet contract requirements. Choose an item. Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period. Choose an item. Provided effective quality control and/or inspection procedures to meet contract requirements. Choose an item. Corrected deficiencies in timely manner and pursuant to the offeror’s quality control procedures. Choose an item. Exhibited knowledge of and compliance with Government (or other) regulations and industry standards. Choose an item. Effectively responded to urgent requests in a timely manner per the Performance Work Statement (PWS). Choose an item. Solved contract performance problems without extensive guidance from procurement or technical personnel. Choose an item. Provided timely and accurate documents, records, and invoices as required by the contract. Choose an item. Rate the Offeror’s OVERALL quality of performance under this contract Choose an item. Would you award similar contracts to this offeror? Please provide explanation for response. EXPLANATION OF OVERALL RATING GIVEN: ADDITIONAL COMMENTS (use additional pages as required) ASSESSOR NAME AND INFORMATION Name & Signature of Assessor’s: Company/Agency: Date: Position Title/Grade: Contracting Officer Phone: Email: Fax: -- 2 of 2 --