2793 - Orthotics.pdf

SHOP DATA SHEET (Orthodics) NOTE: This form must be accurately completed and submitted by the bidder, in duplicate, for each shop owned and operated by said bidder and for all branch shops and/or shops of bidder’s agents at which service will be performed under this contract. The data submitted on this form will be checked for accuracy by the Department of Veterans Affairs. (If space below is not sufficient, please continue information on a separate sheet of paper and attach.) The information requested on this form is solicited under authority of Title 38, "Veterans Benefits", and will be used to assist us in evaluating your facility. It will not be used for any other purpose. Disclosure is voluntary. However, failure to furnish this information will result in delaying the bidding process. It will have no adverse effect on any other benefits to which you may be entitled.

1. NAME OF BIDDER

2. COMPLETE ADDRESS OF SHOP

1A. FULL BUSINESS NAME OF SHOP (If other than item 1)

3. TRADE NAME (If any)

5. HOURS OF BUSINESS

4. DAYS OF BUSINESS

A.M. TO P.M.

THROUGH

NOTE: Firms which have previously held contracts with the Department of Veterans AffairDO NOT need to fill out Item 6 through Item 11, unless changes have 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 (Use reverse side for equipment not 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 (Including officials)

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 hereby certify that the 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