CS# 26-05_ROF VEAPA_AMENDED for Procurement.xlsx
XLSX spreadsheet 459 KB Posted
- Attached to
- R00B6600195 - Vehicle Equipment Adaptation Prescription Agreement (VEAPA) for DORS Client (CS #26-05)
- Solicitation number
- BPM057623
- Issued by
- Maryland
About this file
This file is a Vehicle Equipment Adaptation Prescription and Agreement (VEAPA) workbook and bid form prepared by the Maryland State Department of Education, Division of Rehabilitation Services (DORS) for a single client (CS#26-05). The workbook contains detailed specifications for adaptive vehicle equipment and labor required to modify a 2026 Chrysler Pacifica Select for consumer K. Kuhlman, who has arthrogryposis and uses a powered wheelchair. The modifications include a minivan conversion (E2 conversion with fold-out ramp), primary driving controls (electric shift, joystick steering, electronic left foot accelerator, heavy-duty battery), secondary controls (remote control package with touchscreen and digitone functions), wheelchair securement and restraint systems, specialized adaptations (custom armrest, mouthstick holders, seatback cushion), and wheelchair stowage equipment. The vehicle modifications must be completed within a timeframe to be specified by the winning bidder, with a pre-bid conference scheduled for June 26, 2026, and proposals due July 13, 2026. The contract is effective October 2025 with an initial term and provisions for no-cost extensions if unspent funds remain available.
Bidders must provide itemized pricing for equipment costs and labor costs in the Excel workbook without calculating totals, which are automatically generated. All modifications must comply with NMEDA (National Mobility Equipment Dealers Association) QAP/MQAP certification standards and Federal Motor Vehicle Safety Standards (FMVSS), with full manufacturer warranties required. Bidders must submit references documenting comparable vehicle adaptation services, a Bidder-Offeror Information Sheet, contract affidavit, bid proposal affidavit, and a list of state contracts from the preceding five years. The contract is funded through federal vocational rehabilitation program funds, with payment made within thirty days of invoicing via electronic funds transfer. Liquidated damages are assessed at $29.74 per calendar day for failure to meet delivery timelines. Bidders must follow specific communication protocols with DORS staff, submit invoices through an online portal, and provide comprehensive documentation including NHTSA "Make Inoperable" disclosure forms, warranty documents, and consumer-signed agreements upon contract completion. The mobility equipment dealer is responsible for scheduling fittings with the Certified Driver Rehabilitation Specialist and maintaining communication with DORS throughout the modification process.
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Workbook&Bid Form Instructions DORS CS# 26-05: VEAPA Specifications and Bid Form
Maryland State Department of Education Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B |
| VEAPA WORKBOOK AND BID FORM INSTRUCTIONS |
| This Excel Workbook contains a list of prescribed vehicle equipment as well as the Bid and Signature Form. The different worksheets can be accessed by clicking the different Tabs at the bottom of this Workbook. |
| The Bidder is to provide pricing for "Equipment Cost" and "Labor Cost" in the appropriate cells to the right of each piece of prescribed equipment. Those are the only numbers that are required by the Bidder. |
| Bidders should not calculate any Total Costs. |
| Excel automatically adds and totals each section and then populates those calculations and totals to the last form in the Workbook; which is the "Bid Form & Signatures" Tab. |
| Bidders should not "un-protect" the Workbook or Worksheets within the Workbook. |
| Do not alter the Bid Form or the Bid Form may be rejected. |
| The Bid Form is to be signed and dated, where requested, by an individual who is authorized to bind the Bidder to the prices entered on the Bid form. |
| Bidders must be NMEDA QAP/MQAP certified to be awarded a vehicle modification contract with DORS. |
| If Bidder has difficulty with this Excel Workbook contact Amanda Perkins by email at Amanda.Perkins@maryland.gov for assistance with the Workbook. |
| If Bidder has questions or needs clarification on specifications prescribed in this VEAPA please email them to adrain.pulliam-smith@maryland.gov and copy brittany.owens1@maryland.gov at Maryland State Department of Education (MSDE) procurement. All inquiries must be made in writing via email. |
Work Quality Expectations
| DORS CS# 26-05: VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | |
| DORS Vehicle Modification Work Quality Expectations | |
| 1) | A final fitting/checkout should take place at the completion of the modifications. The client, mobility dealer technician, and driving rehabilitation specialist must be present at this meeting. |
| 2) | All adaptive modifications, installation and equipmment shall meet and/or exceed requirements and standards set forth by NMEDA (National Mobility Equipment Dealers Association) and FMVSS (Federal Motor Vehicle Safety Standards). |
| 3) | All modifications and adaptive equipment shall carry full manufacturer's warranty. |
| 4) | Any changes, deletions, additions, or substitutions to the equipment listed in this Excel Workbook must be pre-approved by the Driving Rehabilitation Specialist and DORS. |
| 5) | Aesthetics (Appearance, function and safety of modifications): All vehicle modifications should include restoration of interior and/or exterior finishing consistent with the original equipment manufacturer (OEM). This shall include, but not limited to, interior lining material on floors, ceilings, and walls; exterior paint; drilled holes; holes left by the necessasry removal of interior accessories and all sharp edges on interior finishing of vehicle. |
MED Communication Responsibilit
| DORS CS# 26-05: VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | |
| Mobility Equipment Dealer (MED) Communication Responsibilities | |
| 1) | Amanda Perkins (Amanda.Perkins@maryland.gov) should be emailed updates at each of the following milestones. People to be cc’d on those updates are as follows: adrain.pulliam-smith@maryland.gov, Brittany.owens1@maryland.gov, brenda.isennock@maryland.gov, DORS counselor and DORS Office supervisor. If appropriate, copy the CDRS and/or consumer: |
| a. | When parts are ordered |
| b. | When consumer’s vehicle is picked up and brought to the shop. |
| c. | When consumer’s van is shipped to Braun, if applicable |
| d. | When consumer’s van is received back from Braun |
| e. | When the vehicle is shipped to EMC or other equipment manufacturer, if applicable. |
| f. | When the vehicle is expected back from the manufacturer. |
g. When the van is back at your shop.
| h. | When vehicle mods are within 3 weeks of completion | |
| i. | When fittings and post mod training are scheduled with Driver Rehabilitation Specialist (DRS) | |
| 2) | Please CC all individuals listed above when sending emails to our consumers and/or the CDRS. | |
| 3) | If problems arise that will delay your schedule of completion, such as shipping delays, wrong parts being received, parts not being received when expected, equipment installation issues, and anytime our consumer’s vehicle will not be at your shop overnight, DORS will need the following information, at a minimum every week, so that we can share with our consumer, what is going on with their vehicle and the progress you are making: |
| a. | Describe the issue with specifics. |
| b. | What you are doing to solve the problem. |
| c. | What is keeping the problem from being resolved. |
| d. | What is the estimated timeframe for solution. |
| e. | If the estimated timeframe passes. |
| f. | If our consumer’s vehicle will not be at your shop overnight, we will need to know the |
reason and when the vehicle will be back at the shop. Weekly updates at a minimum will be needed as long as the vehicle is not in your shop.
g. If the solution will not be resolved within 2 weeks of your contract expiration date it is the responsibility of the Mobility Equipment Dealer to request “Contract Extensions”.
4) It is the mobility equipment dealer’s responsibility to contact the Certified Driver Rehabilitation Specialist (CDRS), who wrote the VEAPA, to schedule all mid and final fittings (give as much scheduling notice as possible because most CDRS’s are scheduled months out). Make sure to copy all of the individuals listed in #1 above on ALL scheduling emails with the DRS and Consumer.
Invoicing & Portal Information
| DORS Invoice and Report Portal Information |
| Invoice Timing: |
Vendors can submit partial invoices after purchasing or putting downpayments on equipment that costs over $5,000.00. Vendors must submit the "paid" receipt from the manufacturer in order for the invoice to be processed and paid.
Final invoice may be submitted upon delivery of modified vehicle to consumer. Invoices need to be itemized to include manufacturer & serial number of all equipment installed in the DORS consumer's vehicle along with the cost to DORS.
Documents to be Submitted along with the Final Invoice:
| * DORS Vehicle Modification Final Receipt & Agreement (RS-6y) Form signed by the consumer. |
| * NHTSA: "Make Inoperable" Disclosure Form |
| * QAP Documents |
| * Company Forms: Electronic copies of all warranty documents. |
| * Company Forms: Provide electronic copies of all documents signed by our DORS consumers |
| Items Required on Invoices: |
| • | Name and Address of Vendor |
| • | DORS Vendor Number/Federal Tax ID: |
| • | “Bill To”: Must be the DORS office that requested the services or purchased the goods. This information will be provided in the written purchase authorization provided by DORS. |
| • | “Remit To” address for payment: Address where DORS should send your payment. |
| • | Invoice #: Must be a unique number for each invoice submitted. |
| • | Invoice Date: Must be the date the invoice is submitted. If resubmitting an invoice after corrections, a new Invoice Date will be needed. |
| • | Consumer Name (Participant): |
| • | Participant ID #: (found on purchase authorization) |
| • | Purchase Authorization Number: |
| • | Description of Services rendered or goods sold: This should be a detailed list of equipment and labor as itemized in the VEAPA and your bid. |
| • | Date(s) of Service: Contract begin date through project completion date (date the consumer takes possession of their modified vehicle) |
| • | Total Amount Due |
These instructions can be found on every DORS “Authorization for Purchase.”
Special Note: If submitting a partial invoice, you will need to submit paid receipt(s) from the manufacturer that you made a purchase from. You must also include the original contracted cost minus what you are invoicing for and the amount remaining on the contract.
| Submitting Invoices through the Portal |
| Portal Address: https://www.surveygizmo.com/s3/5681670/DORS-Invoice-Reports-Portal- 062520 |
| Page 1 |
The first page of the portal provides instructions and guidance on using the portal. Click “Next” to progress through the portal.
Select the first letter of the vendor’s name. Look for and select the vendor name from the drop down list.
Leave it blank if the vendor name was on the list. If the vendor name was NOT on the drop down list, type your vendor name into the provided space.
Blank. Click NEXT.
Type in:
| • | Your name. |
| • | Your email address. |
| • | Additional email addresses (if desired). |
| • | Consumer’s first name [can be found on the Authorization for Purchase. Outlined in purple in the Sample Authorization below]. |
| • | Consumer’s last name [outlined in purple in the Sample Authorization below]. |
| • | DORS Counselor name: Type “Amanda Perkins” in that space; not the DORS counselor |
| • | Select whether you are sending an invoice and report, just a report, or just an invoice. |
| • | Authorization Number [outlined in green in the Sample Authorization below]. |
| • | Case Number [outlined in pink in the Sample Authorization below]. |
| • | Select the DORS Office – Always scroll all the way down the list of offices and choose “Workforce and Technology Center”; not the DORS |
Office location that you see on your authorization.
*** If you choose the DORS Office on the Authorization instead of the "Workforce and Technology Center" we will not receive your invoice and it will not be processed.
Verification page. Verify both the information you have typed, and the selected DORS office location (Workforce and Technology Center) are correct.
Security Question page. You are asked what type of service DORS provides. The answer is “vocational rehabilitation.” Type this in all lower-case letters.
If you answer the security question correctly, you will see this page and it should say “Correct.” If you answer incorrectly, you will be taken back to the beginning of the survey, and all the information entered will be lost.
Files upload page. Select which files to upload. Add any comments to the person processing the documents.
Confirmation page, with the option to download and print all the information entered into the portal. Clicking “NEXT” submits the documents and message.
“Thank You” page. Either close the tab or click the link to enter another invoice and report. If there are comments, feedback or issues, please click the dors.portalfeedback@maryland.gov email address to send a message.
Documents 2 Submit with Invoice Below are the documents that the Mobility Equipment Dealer Needs to Submit along with their Invoice
| NHTSA | "Make Inoperable" Disclosure Form |
| Company Forms | Provide electronic copies of all documents signed by our DORS consumers |
| Company Forms | Electronic copies of all warranty documents. |
| Itemized Invoice | Invoices need to be itemized to include manufacturer & serial number of all equipment installed in the DORS consumer's vehicle. |
VEAPA Consumer-Vehicle Info
| DORS CS# 26-05: VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | |
| Consumer and Vehicle Information | |
| Certified Driving Rehabilitation Specialist (CDRS) Name and Credentials: | Timothy Jones OTR, CDRS, CDI |
| Date of VEAPA: | 9/4/25 |
| Consumer Information: | |
| Consumer's First Initial & Last Name: | K. Kuhlman |
| Participant ID#: | 233573 |
| Address (Town, State only): | Poolesville, Maryland 20837 |
| Disability/Functional Limitations related to driving: | Arthrogryposis |
| Purpose for Driving/Vehicle Modifications: | Employment and independence in the community |
| Consumer will be driver and passenger: | Yes |
| Consumer uses Wheelchair (W/C) or Scooter? | Wheelchair |
| If Consumer Uses a W/C; Is it Manual or Powered? | Powered Pride Q6 Edge 3 |
| If Consumer Uses a Wheelchair or Scooter, See "Wheelchair/Scooter Worksheet" Tab of this Workbook. | |
| Consumer's Weight: | 140 |
| If in Wheelchair; height from floor to top of head: | < 53" |
| Consumer can transfer to OEM vehicle seat independently: | Yes |
| Does consumer use a transfer aid? If so; what type: | No |
| Consumer can use a swivel transfer seat: | Y-6 way |
| List any Drivers' License restrictions: | LFA, Joystick steering, remote functions, touchpad |
| DORS Field Counselor Name: | Shanicia Hanson |
| DORS Field Counselor Phone Number: | 301-601-1500 |
| Vehicle Information | |
| After Approvals have been obtained and the Vehicle is purchased by consumer, list the Make, Model, Year and Mileage, VIN: | 2026 Chrysler Pacifica Select, Miles: 5, VIN: 2C4RC1BG3TR217955 |
| Vehicle Make, Model, Year and Mileage: | |
| Vehicle purchased by consumer (VIN#): | |
| End of Worksheet |
Wheelchair-Scooter Stowage
| DORS CS# : VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | |||||
| Wheelchair/Scooter Stowage Equipment Specifications | |||||
| Modification Type | Existing | Needed | Equipment Description and/or Instructions | Equipment Cost | Labor Cost |
| Wheelchair/Scooter Lift/Carrier: | |||||
| Other: | |||||
| Other: | |||||
| 1 Year of Maintenance for Stowage Equipment (Parts & Labor): | Y | ||||
| Totals = | $ - 0 | $ - 0 | |||
| Total Equipment + Labor = | $ - 0 | ||||
| Notes: |
Securement-Restraint Sys Wrksht
| DORS CS# 26-05: VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | |||||
| Wheelchair/Consumer Restraint System Specifications | |||||
| Modification Type | Existing | Needed | Equipment Description and/or Instructions | Equipment Cost | Labor Cost |
| Power 6-Way transfer seat: | Y | B&D 6 way. Consumer needs custom built up right armrest of OEM driver seat to act as a filler and rest her right elbow on while using joystick steering. Needs to flip up for ingress and egress. | |||
| Power driver transfer seat handheld remote: | Y | Handheld remote needed for ingress/egress | N/A | N/A | |
| Power driver transfer seat override switch location: | Y | Needs to be mounted within her reach to use mouthstick to activate | N/A | N/A | |
| Power WC/Scooter docking station (unoccupied-consumer in drivers' seat): | Y | QLK-170 mounted in midrow. Consumer will need to use a mouthstick to activate release pad positioned in midrow-Placement TBD | |||
| Wheelchair Tiedown Bracket: | |||||
| Consumer's Body Restraint System (e.g. OEM, 2-point, 3-point, rigid seat belt extension, etc.) | Y | Uses OEM. Will need fleece liner over seatbelt shoulder strap and 4" female rigid extension to help with fastening seatbelt | |||
| Other Restraint Equipment: | Y | Custom seatback cushion in driver seat to act as filler and take out hammocking effect. | |||
| Other Restraint Equipment: | Y | Loopo seatbelt clip to keep seatbelt from retracting so far. | |||
| Other Restraint Equipment: | Y | Custom mouthstick holder in midrow for consumer to reach with mouth and release QLK prior to placing mouthstick back in cup or "holder" | |||
| 1 Year of Securement Equipment Maintenance (Parts & Labor): | Y | ||||
| Totals = | $ - 0 | $ - 0 | |||
| Totals Equipment + Labor Costs = | $ - 0 |
Primary Driving Controls Wrksht
| DORS CS# 26-05: VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | |||||
| Primary Driving Controls Specifications | |||||
| Modification Type | Existing | Needed | Equipment Description and/or Instructions | Equipment Cost | Labor Cost |
| Electric Shift (Transmission) (provide manufactuer and any other specifying information): | Y | EMC (See Secondary Controls Worksheet) | |||
| AVPS 2 (Auxillary Vehicle Power Supply) from EMC: | |||||
| Secondary Battery: | |||||
| Joystick Steering (provide manufacturer and any other specifying information): | Y | EMC Aevit J-X axis steering only on the right. Custom 3D orthotic is 2 1/2" length X 1 1/2" width "tear drop" custom handle-see photo during pre-bid | |||
| Electronic Left Foot Accelerator (provide manufacturer and any other specifying information): | Y | Mobility Innovations E- LFA with "ready" state ignition upon powering up vehicle. Placement TBD by consumer for her to use her left foot. Possible brake pedal extension TBD during fitting process. | |||
| Heavy Duty Battery: | Y | ||||
| 1 Year of Primary Controls Equipment Maintenance (Parts & Labor): | Y | ||||
| Totals = | $ - 0 | $ - 0 | |||
| Totals Equipment + Labor Costs = | $ - 0 | ||||
| End of Worksheet |
Secondary Controls Worksheet
| DORS CS# 26-05: VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | |||||
| Secondary Controls Specifications | |||||
| Modification Type | Existing | Needed | Equipment Description and/or Instructions | Equipment Cost | Labor Cost |
| Remote Secondary Control Package (provide manufacturer and any other specifying information): | Y | Aevit Gen X 2.0 Option A secondary control package with digitone addition (8 functions), and Aux. functions of 8 functions on screen.(Mirrors (3),Rear defrost, bluetooth, rear hatch, rear wiper, ramp deployment) | |||
| Remote Secondary Control Touchscreen Location: | Y | Left of consumer for her to use mouthstick to activate. Need custom mouthstick holder she can reach with mouth | N/A | N/A | |
| Remote Secondary Control Access Method: | Y | Jastick 18" mouthstick ordered from Amazon X 2. Need for touchscreen and QLK release in midrow. 1.5" jellyean switch that consumer will hold in left hand to activate digitone. Please hang in such a fashion she can access once in driver seat. | |||
| Other: | Y | HVAC addition through EMC touchscreen | |||
| Other: | Y | All shfiting will be completed through digitone (8 functions needed) | |||
| 1 Year of Secondary Control Equipment Maintenance (Parts & Labor): | Y | ||||
| Totals = | $ - 0 | $ - 0 | |||
| Totals Equipment + Labor Costs = | $ - 0 | ||||
| End of Worksheet |
Transportation &Additional Mods
| DORS CS# 26-05: VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | |||||
| Transport of Vehicle and Consumer & Additional Miscellaneous Modifications | |||||
| Modification Type | Existing | Needed | Equipment Description and/or Instructions | Equipment Cost | Labor Cost |
| Vehicle Pick-up and Delivery Charge: | Y | Poolesville, MD | N/A | ||
| Consumer pickup and dropoff for all fittings: | Y | Poolesville, MD | N/A | ||
| Additional Modifications: | Y | NIDB.org smart view mirrors to both OEM side mirrors | |||
| Additional Modifications: | Y | Pre-bid meeting needed | |||
| Totals = | $ - 0 | $ - 0 | |||
| Total Equipment + Labor = | $ - 0 | ||||
| End of Worksheet |
Minivan Conversion Worksheet
| DORS CS# 26-05: VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | ||||
| Minivan Conversion Specifications | ||||
| Conversion Specifics | Existing | Needed | Equipment Description and/or Instructions | |
| Make, Model, Year and VIN# of Vehicle: | ||||
| (Just put make, model & year recommended if consumer has not purchased a vehicle yet) | N/A | N/A | 2026 Chrysler Pacifica Select, Miles: 5, VIN: 2C4RC1BG3TR21795 | |
| Conversion Manufacturer and Conversion Type (e.g. E2, XI, XT, etc.) | Y | E2 conversion on a qualifiable Chrysler Pacifica | ||
| Ramp Type (e.g., In-Floor, Fold-out): | Y | Fold out | ||
| Lift Type: | Y | Automatic | ||
| Transmission Type (e.g., Automatic, 2-Wheel Drive, All Wheel Drive ) | Y | AT | ||
| Lowered Floor cut location (e.g. rear axle to firewall): | Y | |||
| Door Opening Height Required: | Y | >52" | ||
| Interior Height at Center of Vehicle Required: | >52" | |||
| Quick release front driver seat: | Y | |||
| Tie down track covers (identify location): | No | N/A | ||
| Rubber Flooring to replace carpeting : | Y | |||
| 1 Year of Conversion Maintenance (Parts & Labor): | Y | |||
| Minivan Conversion Cost = | ||||
| End of Worksheet |
Conversion other than Minivan
| DORS CS# : VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | |||
| Full Size Van/SUV/Truck Conversion Specifications | |||
| Conversion Specifics | Existing | Needed | Equipment Description and/or Instructions |
| Make, Model, Year of Existing Vehicle or Recommended Vehicle: | |||
| Conversion Manufacturer and Conversion Type (e.g. E2, XI, XT, etc.) | |||
| Entry Type: Side, Front, Rear: | |||
| Entry Side (Driver or Passenger): | |||
| Lift Type: | |||
| Transmission Type (e.g., Automatic, 2-Wheel Drive, All Wheel Drive ) | |||
| Lowered Floor cut location (e.g. center section, center & driver, center & passenger, full:center, driver & passenger): | |||
| Door Opening Height Required: | |||
| Interior Height at Center of Vehicle Required: | |||
| Interior Height at Driver/Passenger Position Required: | |||
| Quick release front driver seat: | |||
| Quick release front passenger seat (give justification if recommending both driver and passenger side quick release feature) | |||
| Wheelchair tie down tracks location: | |||
| Tie Down Track Covers: | |||
| Wheelchair stowage method and location: | |||
| Remote control entry system (indicate number of FOB's): | |||
| Flooring covering type (altro, rubber, carpet, etc.): | |||
| Power door features needed (e.g. manual release feature): | |||
| Raised reinforced roof (indicate height of modification): | |||
| Raised reinforced door (indicate height of modification): | |||
| Roll Cage: | |||
| Other conversion feature: | |||
| Other conversion feature: | |||
| Other conversion feature: | |||
| Specialized customizations needed: | |||
| Specify reason for customization: | |||
| Specialized customizations needed: | |||
| Specify reason for customization: | |||
| 1 Year of Conversion Maintenance (Parts and Labor): | Y | ||
| Cost of Full Size Van or Truck Conversion = | |||
| Notes: | |||
| Does consumer want any of their seats or accessories back?(Please make sure that they know that there will be a shipping charge for that service that they will be responsible for): | |||
| Specify which seats and/or accessories the consumer wants returned to them by the conversion company: |
Wheelchair-Scooter Worksheet
| DORS CS# 26-05: VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | |
| Wheelchair (W/C)/Scooter Specifications Worksheet | |
| Wheelchair (Power or Manual) or Scooter? | Power wheelchair |
| Make, Model & Serial Number | Pride Quantum Q6 Edge 3.0 |
| Floor to top of head measurement | 52.5 |
| Eye height measurement | 48 |
| Consumer Weight | 105 |
| Width at drive wheels | 24 |
| Width at widest point | 24 |
| Tip of toes to rear most point on wheelchair when in driving position | 48 |
| Seat height w/cushion with consumer in the W/C | 20 |
| Knee height from floor to top of knees | 22 |
| Ground clearance at battery box | 2.5 |
| Armrest height | 31 |
| Armrest style | canter lever |
| Rigid or Conventional Folding Frame | |
| Power assist wheels for manual W/C. If "Yes" which manufacturer & model? | |
| Removable wheels | |
| Wheelchair Back Style | solid shoulder hieght |
| Wheelchair Back Height (Indicate what level of spine the chair back rises to (e.g.; T4-5); are there lateral supports?) | shoulder height |
| Wheelchair back width | 16 |
| Wheelchair Back height, folded down | |
| Wheelchair folded width | |
| Power Wheelchair drive system | Pride |
| Power Wheelchair Elevating Seat Feature? If "Yes" how many inches? | 10"power elevating |
| Power Positioning Components (Tilt, Recline, etc.) | power elevating seat only |
| Power Positioning Components Manufacturer | Pride Quantum Q6 Edge 3.0 |
| Power Wheelchair Weight w/Accessories | 300 |
| Foot rest type/style/removable/power | split platform |
| Wheelchair Joystick side | right |
| Wheelchair joystick style (e.g. fixed, articulating, hinged) | swing away |
| Headrest type (flat, soft, three section, molded, lateral control, adjustable, etc.) | no headrest |
| Wheelchair headrest height measurement | N/A |
| 4-Point tie down anchors present? | yes |
| Existing Power W/C Tie-Down Bracket? Yes/No. If "Yes" which manufacturer? | no |
Bid Form & Signatures
| DORS CS# 26-05: VEAPA Specifications and Bid Form |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| ATTACHMENT B | |||||
| Bid Form and Signatures | |||||
| Equipment | Labor | ||||
| Transport of Consumer-Vehicle: | $ - 0 | ||||
| Primary Driving Controls: | $ - 0 | ||||
| Secondary Controls: | $ - 0 | ||||
| Securement-Restraint System: | $ - 0 | ||||
| Wheelchair-Scooter Stowage: | $ - 0 | ||||
| Transport of Consumer-Vehicle: | $ - 0 | ||||
| Primary Driving Controls: | $ - 0 | ||||
| Secondary Controls: | $ - 0 | ||||
| Securement-Restraint System: | $ - 0 | ||||
| Wheelchair-Scooter Stowage: | $ - 0 | ||||
| Equipment and Labor Subtotals from | |||||
| all Worksheets = | $ - 0 | $ - 0 | |||
| Total Equipment and Labor from all Worksheets = | $ - 0 | ||||
| Minivan Conversion Total: | $ - 0 | ||||
| Total Bid Price | $ - 0 | ||||
| How long after receipt of contract will the consumer's vehicle be picked up for modifications? | |||||
| How long after receipt of contract will | |||||
| work begin? | days or | weeks | |||
| How long to complete the vehicle | |||||
| modification project? | days or | weeks | |||
| All modifications must conform to Federal and State vehicle safety regulations. Bidders must be NMEDA QAP/MQAP certified in order to be awarded a contract with DORS. |
Quotations/bids are firm and must be guaranteed for 120 days after the due date. Authorization to begin the project may be anytime within the 90 day period. The vendor is responsible for providing the consumer with the appropriate specifications, diagrams, and warranties for all parts and labor which shall be for a minimum of one year from the date of project completion.
Vehicle Modification Company Name
| Vehicle Modification Company Address | |
| Vehicle Modification Company Federal ID# | eMM#: |
Signature - Authorized Vendor Representative Date
Printed Name of Authorized Vendor Representative and Position/Credentials
Email Address Telephone Number
Signature of Authorized DORS Representative Date
| Printed Name of Authorized DORS Representative and Position/Credentials |
| End of Worksheet |
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