2130.pdf

INSPECTION SHEET - PROSTHETIC DEALER

4. BUSINESS HOURS

PART I - DESCRIPTION OF PHYSICAL FACILITIES AND PERSONNEL

21. FACILITIES FOR TRAINING20. PERSONNEL

NOYESITEMSNUMBERSITEM

PART II - PRODUCTS

*RATING OF

FINISHED PRODUCTS

NOT UNDER

CONTRACT

UNDER LOCAL

CONTRACT

UNDER CENTRAL

OFFICE CONTRACTPRODUCTS FURNISHED BY DEALER

VA FORM

AUG 1994(R) 2130 JetForm

5. CURRENT CENTRAL OFFICE CONTRACT NUMBERS

2. ADDRESS (Street,City, StateandZIP Code)

A. MONDAY THROUGH FRIDAY

6. CURRENT LOCAL CONTRACT NUMBERS

3. NAME AND TITLE OF PRINCIPAL EXECUTIVE (Owneror Manager)

B. SATURDAY

PM

9. NEAR BUS OR TROLLEY LINE

22. COMMENTS

AM TO

1. NAME OF COMPANY

SQ. FT.

PM

11. CONDITION OF BUILDING (Checktwo)

YES NO

YES NO

(7) OTHER

YES

YES NO

BUSINESS BLDG.

NO

BRICK

CLUTTERED

RESIDENCE

APPEARS ADEQUATE

POOR

OLD

YES

7. DISTANCE FROM LOCAL VA STATION

17. APPROXIMATE FLOOR SPACE IN WORKSHOP

ONLY

19. ADEQUACY AND CONDITION OF EQUIPMENT (Checktwo)

16. APPROXIMATE TOTAL FLOOR SPACE OCCUPIED

BY FIRM

13. CONDITION OF SAMPLES

NEW GOOD POOR

EXCELLENT FAIR

12. SAMPLE FINISHED PRODUCTS AVAILABLE

15. FITTING ROOM ACCESSIBLE TO WHEEL

CHAIR PATIENTS

AM TO

SQ. FT.

14. PRIVATE ROOMS FOR FITTING

10. TYPE OF BUILDING (Checktwo)

23. EXPLANATION OR REMARKS

NO

POORGOOD CONDITIONINADEQUATECLEAN

FRAME

NEATDIRTY

* Shouldbebaseduponcombinationof your own evaluationandgeneralexperienceof local field stations.Usestandardratingtermsoutlinedin PartIV, backof form. Explainall "POOR"ratingsin item 23 below.

A. ARTIFICIAL LEGS

B. ARTIFICIAL ARMS

C. BRACES

D. BELTS AND TRUSSES

E. ELASTIC HOSE

H.

(1) STANDARD PTB BELOW KNEE LEGS

(2) SPECIAL SOCKETS FOR PTB LEGS (Variants)

(3) TOTAL CONTACT AK SOCKETS

(4) ALL FLUID CONTROL LEGS

(5) HYDRA - CADENCE FLUID CONTROL ONLY

(6) IMMEDIATE POST SURGICAL OR EARLY FITTING SERVICE

8. ADEQUATE PARKING FACILITIES

F. ORTHOPEDIC SHOES

G.

18. GENERAL CONDITION AND APPEARANCE OF SHOP (Checktwo)

A. PARALLEL BARS

B. FULL-LENGTH MIRRORS

C. RAMPS

E. OTHERE. CERTIFIED PROSTHETISTS OR ORTHOTISTS

F. SPECIALLY QUALIFIED PROSTHETISTS:

D. STEPS

A. JOURNEYMAN TECHNICIANS

B. APPRENTICE TECHNICIANS

C. ALL OTHERS

D. TOTAL PERSONNEL (IncludingManager)

PART III - SERVICE AND WORK RELATIONSHIP

41. GENERAL EVALUATION

PART IV - SPECIAL INFORMATION AND GENERAL EVALUATION

*POINTSPOORAVERAGEABOVE AVG.SUPERIORELEMENTS

*FOR CENTRAL OFFICE USE ONLY.

MONTHS

NO (If "YES,"describedifficulty)

29. IS THERE EVIDENCE OF EXCESSIVE COMPLAINTS FROM VETERANS AGAINST THIS DEALER?

YEARS

24. IS THERE A CLINIC TEAM OPERATING IN A LOCAL VA STATION

SERVED BY THE DEALER?

YES

YES

YES NO

OVER 75%

NO

YES NO (If "YES,"describebriefly)

LESS THAN 10% 10% TO 25% 25% TO 50% 50% TO 75%

YES NEVERNO

YES NO YES NO

YES NO (If "YES,"describebriefly)

YES

37. METHOD OF DETERMINING PRICES TO BE CHARGED TO VA

YES NO

REGULARLY OCCASIONALLY

32. ARE PROSTHETIC SERVICE CARD INVOICES

NORMALLY REASONABLE AND ACCURATE?

38. APPROXIMATE PERCENTAGE OF DEALERS’ TOTAL ANNUAL DOLLAR SALES MADE TO DEPARTMENT OF VETERANS AFFAIRS

25. IF ITEM 24 IS "YES," THEN DOES DEALER PARTICIPATE IN CLINIC SESSIONS?

26. IF DEALER PARTICIPATES IN CLINIC SESSIONS, WHAT IS THEIR HONEST OPINION OF THE CLINIC TEAM?

27. IF DEALER DOES NOT PARTICIPATE IN CLINIC SESSIONS, WHAT REASONS DO THEY GIVE?

28. IS THERE EVIDENCE OF FRICTION BETWEEN THIS DEALER AND PERSONNEL IN LOCAL VA STATIONS?

40. LENGTH OF TIME DEALER HAS BEEN IN PROSTHETIC BUSINESS

30. ARE MOST APPLIANCES DELIVERED WITHIN

REASONABLE TIME?

31. DOES DEALER COOPERATE FULLY WITH LOCAL VA

STATIONS IN EMERGENT OR DIFFICULT CASES?

NO (If "YES,"explain)

33. REMARKS (Explain"NO," answersto 30 through32,above. List anycomplaintsof dealeragainstVA)

34. IS DEALER CONDUCTING SPECIFIC RESEARCH OR DEVELOPMENT ON PROSTHETIC DEVICES?

35. DOES DEALER PRODUCE DEVICES OF THEIR OWN DESIGN NOT AVAILABLE ELSEWHERE?

36. DOES DEALER MAINTAIN ADEQUATE COST - ACCOUNTING SYSTEM

FOR DETERMINATION OF ACTUAL COSTS OF EACH ITEM FABRICATED

OR SOLD?

Based upon your inspection of this dealers facilities and products; the opinions expressed Physicians and Prosthetic Personnel in local VA stations; and any other knowledge you may have concerning the company or its services, check your overall rating for each of the elements below.

39. DOES COMPANY CLAIM CERTIFICATION BY AMERICAN BOARD?

A. WORKMANSHIP, FIT AND ALIGNMENT OF APPLIANCES

C. COMPARATIVE USEFUL LIFE OF APPLIANCES

D. PROMPTNESS OF DELIVERY

E. QUALITY AND PROMPTNESS OF SERVICES AND REPAIRS

F. COOPERATIVENESS WITH VA AND VETERANS SERVED

G. ADEQUACY OF EQUIPMENT AND PERSONNEL

I. GENERAL OVERALL EVALUATION OF COMPANY

JetForm

45. DATE OF REPORT

H. CLEANLINESS AND ACCESSIBILITY OF SHOP

BACK OF VA FORM 2130, AUG 1994 (R)

42. GENERAL REMARKS (If additionalspaceis required,attachadditionalsheet.)

43. SIGNATURE AND TITLE OF REPORTING OFFICIAL 44. DATE OF INSPECTION

B. QUALITY OF MATERIALS USED IN FABRICATION