13.EXHIBIT 1 36C25625Q0722 DELIVERY CHECKLIST.pdf
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- Solicitation number
- 36C25625Q0722
About this file
Exhibit 1 is a detailed Delivery Checklist for Durable Medical Equipment (DME) and Home Medical Equipment (HME) delivery, designed to ensure quality service and proper equipment handling. The checklist is divided into two sections: Section I to be completed by the veteran patient/caregiver and Section II to be completed by the delivery person. Each section includes multiple checkboxes to verify key aspects of equipment delivery, such as cleanliness, functionality, instruction provision, electrical safety, and proper handling of recovered equipment.
The checklist requires signatures from both the veteran patient/caregiver and the delivery person, along with the date of delivery. It serves as a systematic approach to documenting the delivery process, ensuring accountability, and confirming that all necessary steps have been taken during equipment delivery. The form provides a standardized method for tracking the condition of medical equipment, verifying instructions were given, and maintaining a record of the delivery transaction.
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Text version
EXHIBIT 1 – DELIVERY CHECKLIST
SECTION I- TO BE SIGNED BY VETERAN PATIENT/CAREGIVER YES NO
1. Did items delivered appear clean? 1. ( ) ( )
2. Did equipment appear to be working properly at time delivery? 2. ( ) ( )
3. Were you given instructions in the care and mechanical use of 3. ( ) ( )
The equipment
4. You are responsible for assuring that any electrical outlets needed 4. ( ) ( )
For prescribed equipment are properly grounded and safe for such equipment. Were you informed of this requirement?
5. Were you provided with a receipt or delivery notice showing the 5. ( ) ( ) name & telephone number of the contractor in the event service or repairs are needed?
SIGNATURE OF VETERAN PATIENT/ CAREGIVER DATE
SECTION II-TO BE COMPLETED BY DELIVERY PERSON YES NO
1. Was equipment working properly at time of delivery 1. ( ) ( )
2. Were electrical cords, plugs, etc. undamaged? 2. ( ) ( )
3. Did you instruct veteran/caregiver in the proper care and 3. ( ) ( )
Mechanical use of delivered equipment?
4. If veteran/caregiver had questions about equipment which 4. ( ) ( ) you could not answer, did you contact either the contractor or Prosthetics personnel?
5. Did you provide a receipt or delivery notice showing 5. ( ) ( ) Contractor’s name and telephone number?
6. If recovered equipment was picked-up during this or a prior 6. ( ) ( ) Delivery this day, did you segregate such equipment from New/cleaned items and use prescribed precautions for handling Such equipment?
SIGNATURE OF DELIVERY PERSON DATE
File details come from the government source that posted it. Updated .