2793.pdf

SHOP DATA SHEET (ARTIFICIAL LIMBS)

NOTE: This form mustbe accuratelycompletedandsubmittedby the bidder,in duplicate,for eachshopownedandoperatedby saidbidderandfor all branchshops and/orshopsof bidder’sagentsat which servicewill beperformedunderthis contract. Thedatasubmittedon this form will becheckedfor accuracyby theDepartment of VeteransAffairs. (If spacebelow is not sufficient, pleasecontinueinformationon a separatesheetof paperandattach.) The information requestedon this form is solicitedunderauthorityof Title 38, "VeteransBenefits",andwill beusedto assistus in evaluatingyour facility. It will not beusedfor anyotherpurpose.Disclosureis voluntary. However,failure to furnishthis informationwill resultin delayingthebiddingprocess.It will haveno adverseeffecton anyotherbenefitsto which you may be entitled.

1. NAME OF BIDDER

2. COMPLETE ADDRESS OF SHOP

1A. FULL BUSINESS NAME OF SHOP (If otherthanitem1)

3. TRADE NAME (If any)

5. HOURS OF BUSINESS

4. DAYS OF BUSINESS

A.M. TO P.M.

THROUGH

NOTE: Firms whichhavepreviouslyheldcontractswith theDepartmentof VeteransAffair DO NOT needto fill out Item6 throughItem11,unlesschangeshave occurred.

8A. IF "NO" IS CHECKED IN ITEM 8, GIVE NAME AND

ADDRESS OF YOUR PRINCIPAL SUPPLIER

NO

14. NUMBER OF FULL-

TIME QUALIFIED LIMB

FITTERS EMPLOYED

9. IS IT COMMON PRACTICE TO REQUIRE

A PHYSICIAN’S PRESCRIPTION AS A

CONDITION FOR FITTING OF CIVILIAN

AMPUTEES?

YES

8. DOES YOUR SHOP

USUALLY MAKE ITS

OWN "SET-UPS?"

7. NUMBER OF YEARS

EXPERIENCE IN ARTIFICIAL

LIMB BUSINESS AT OTHER

LOCATIONS

YES NO

26. INDICATE NUMBER AND TYPE OF SHOP EQUIPMENT (Usereversesidefor equipmentnot listed)

A. NAME AND LOCATION OF ORGANIZATION B. NAME AND LOCATION OF ORGANIZATION

10. IF YOUR FIRM HAS BEEN IN BUSINESS LESS THAN 3 YEARS, LIST TWO BUSINESS REFERENCES (Including bank reference)

11. GIVE NAMES AND ADDRESSES OF CIVILIAN PHYSICIANS WHO HAVE REFERRED PATIENTS TO YOUR SHOP

16. NAMES AND CERTIFICATE NUMBERS OF CERTIFIED SUCTION SOCKET FITTERS (If none,write "none")

CERTIFICATE NUMBER

B. NAME AND OFFICE ADDRESS C. NAME AND OFFICE ADDRESS

15. NUMBER OF PROSTHETISTS EMPLOYED WHO HAVE SUCCESSFULLY COMPLETED ONE OR

MORE OF THE FOLLOWING POST-GRADUATE COURSE IN PROSTHETICS (If none,write "none")

A. UPPER EXTREMITY COURSE

6. NUMBER OF YEARS

EXPERIENCE IN ARTIFICIAL

LIMB BUSINESS AT

PRESENT ADDRESS

12. TOTAL NUMBER OF

EMPLOYEES IN THE

SHOP (Includingofficials)

13. NUMBER OF EMPLOYEES

ENGAGED IN THE

FABRICATION OF LIMBS

B. A/K PROSTHETICS

COURSE

C. OTHER (Specify)

23. IS SHOP EQUIPPED WITH PARALLEL BARS FOR WALKING TRAINING?

OTHER

(Specify)

A. NAME AND OFFICE ADDRESS

B. NAME

18A. IF ITEM 18 IS "NO," ARE ELEVATORS AVAILABLE

A. NAME CERTIFICATE NUMBER

PRIVATE

RESIDENCE

OFFICE

BUILDING

YES NO

YES NO

18. IS FITTING ROOM ON GROUND FLOOR

25. IS SHOP EQUIPPED WITH RAMPS?

SQ. FT.

TYPE

19. TOTAL FLOOR SPACE OCCUPIED BY

SHOP

NUMBER

SQ. FT.

17. SHOP LOCATED IN

20. TOTAL FLOOR SPACE IN WORKSHOP

NOYES

24. IS SHOP EQUIPPED WITH FULL-LENGTH

MIRRORS?

SQ. FT.

21. TOTAL FLOOR SPACE IN FITTING ROOM

YES NO

SQ. FT.

22. TOTAL OFFICE FLOOR SPACE

ITEM

YES NO

TYPENUMBERITEM

F. DRILL PRESS

E. LATHE

(WOOD-TURNING)

D. FLEXIBLE

SHAFT SANDER

C. SANDING ARBOR

B. SANDING DISC

A. BAND SAW

L. OTHER (Specify)

K. ALIGNMENT JIG

J. WELDING

EQUIPMENT

G.SEWING MACHINE

I. PAINT-SPRAYING

EQUIPMENT

CERTIFICATION: I do herebycertify thatthe above statements are true and correct to the best of my knowledge and belief.

SIGNATURE AND TITLE

H. GRINDING

EQUIPMENT

DATE

JetFormVA FORM

MAR 2002(RS) 2793