CS# 26-06_ROF_VEAPA.xlsx
XLSX spreadsheet 464 KB Posted
- Solicitation number
- BPM057724
- Issued by
- Maryland
About this file
This is a Vehicle Equipment Adaptation Prescription Agreement (VEAPA) workbook and bid form issued by the Maryland State Department of Education Division of Rehabilitation Services (DORS) for the modification of a 2026 Toyota Sienna XSE (VIN: 5TDXRKEC8TS30755). The project involves comprehensive adaptive vehicle modifications for consumer S. Lamkin, a individual with cerebral palsy and left hemiparesis who requires employment and community independence accommodations. Required modifications include a power in-floor minivan conversion (XI conversion type), primary driving controls (electronic hand controls with gas/brake, steering knob, heavy-duty battery), secondary controls (remote control package with digitone functions), wheelchair/scooter restraint systems (power six-way transfer seat, CCI power docking station for mid-row scooter), and transportation and consumer pickup/delivery services. All work must comply with National Mobility Equipment Dealers Association (NMEDA) QAP/MQAP certification standards and Federal Motor Vehicle Safety Standards (FMVSS). Bidders must submit pricing for equipment costs and labor costs within the Excel workbook template, which automatically calculates totals for the bid form. The bid form requires signatures from an authorized vendor representative and must guarantee firm quotations for 120 days after the due date, with authorization to begin work within a 90-day period.
Bidders must be NMEDA QAP/MQAP certified to be awarded the contract and must comply with all work quality expectations including final fitting/checkout with the client, mobility dealer technician, and driving rehabilitation specialist present. The mobility equipment dealer is responsible for detailed communication with DORS at specified project milestones, weekly updates if the vehicle is not at the shop, and scheduling all fittings with the Certified Driver Rehabilitation Specialist (Timothy Jones, OTR, CDRS, CDI). Invoicing procedures require vendors to submit itemized invoices through the DORS portal with detailed equipment information, manufacturer details, serial numbers, and supporting documentation including NHTSA "Make Inoperable" Disclosure Forms, QAP documents, and warranty information. Partial invoices may be submitted after purchasing equipment costing over $5,000 with paid manufacturer receipts; final invoices are submitted upon vehicle delivery to the consumer. All modifications must include manufacturer's warranties for a minimum of one year from project completion and restoration of interior/exterior finishing consistent with original equipment manufacturer specifications. The contract includes one year of maintenance (parts and labor) for stowage, securement, primary controls, secondary controls, and conversion equipment.
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Workbook&Bid Form Instructions DORS CS# 26-06: 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 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# 26-06: 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# 26-06: 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: 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 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 |
| 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# 26-06: 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: | 11/7/25 |
| Consumer Information: | |
| Consumer's First Initial & Last Name: | S. Lamkin |
| Participant ID#: | 262614 |
| Address (Town, State only): | Salisbury, Maryland 21804 |
| Disability/Functional Limitations related to driving: | CP with left hemiparesis |
| Purpose for Driving/Vehicle Modifications: | Emloyment and independence in the community |
| Consumer will be driver and passenger: | Yes |
| Consumer will be driver only: | No |
| Consumer will be passenger only: | No |
| Consumer uses Wheelchair (W/C) or Scooter? | Yes |
| If Consumer Uses a W/C; Is it Manual or Powered? | Power scooter |
| If Consumer Uses a Wheelchair or Scooter, See "Wheelchair/Scooter Worksheet" Tab of this Workbook. | |
| Consumer's Weight: | 115 |
| If in Wheelchair; height from floor to top of head: | Scooter 54 1/2" height |
| Consumer can transfer to OEM vehicle seat independently: | Yes, with 6 way power seat |
| Does consumer use a transfer aid? If so; what type: | No |
| Consumer can use a swivel transfer seat: | Yes |
| List any Drivers' License restrictions: | Hand controls, steering knob, remote functions |
| List any Learners' Permit Restrictions: | |
| DORS Field Counselor Name: | Patrice Winder |
| DORS Field Counselor Phone Number: | 410-546-1580 |
| Vehicle Information | |
| * CONSUMERS NEED TO SPEAK TO RTS DRIVING PROGRAM SUPERVISOR PRIOR TO PURCHASING A VEHICLE | |
| * CONSUMERS SHOULD NOT PURCHASE A VEHICLE UNTIL GIVEN DORS APPROVAL TO DO SO | |
| ** DORS cannot be held responsible for financial losses due to vehicle purchases made without compliance with the above ** | |
| DRS/CDRS Approved make, model and year vehicle the consumer is planning on purchasing after appropriate approvals are obtained: | |
| Required OEM Equipment: | |
| Automatic Transmission | |
| 2-Wheel Drive Transmission | |
| Power sliding door(s); (Left?, Right?, Rear?) | |
| Power Locks | |
| Power Mirrors | |
| Power Seats | |
| Power Windows | |
| Remote Start | |
| Push-Button Start | |
| Power Steering, Tilt and/or Telescoping Wheel | |
| Heavy Duty Battery | |
| Self Load Leveling | |
| Tow Package | |
| Other recommended OEM Equipment not listed above: |
| If consumer, or their family member already owns a vehicle intended for modification; list the Make, Model, Year, Mileage and VIN#.: |
| AFTER VEHICLE MODIFICATIONS ARE ON AN APPROVED, DATED AND ISSUED IPE ------ |
The consumer works with their CDRS to purchase a vehicle that is compatible with all of his/her adapted driving equipment and conversion, if applicable.
| After Approvals have been obtained and the Vehicle is purchased by consumer; list the Make, Model, Year and Mileage: | 2026 Toyota Sienna XSE, VIN: 5TDXRKEC8TS30755, Mileage: 3 |
| 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# 26-06: 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 | |||
| Power driver transfer seat switch box location: | Y | Standard | N/A | N/A | |
| Power driver transfer seat handheld remote: | Y | Yes | N/A | N/A | |
| Power driver transfer seat override switch location: | Y | Standard location | N/A | N/A | |
| Power turning, lowering & raising into driver position seat to get in and out of the vehicle (indicate manufacturer, make & model): | |||||
| Manual Wheelchair (WC) Restraint System (Do not specify here if already included on the Braun Conversion: | |||||
| Manual WC Restraint System Location: | N/A | N/A | |||
| Power WC/Scooter docking station (unoccupied-consumer in drivers' seat): | Y | CCI securement station in midrow. Consumer will back in with scooter prior to transfer. | |||
| Power WC/Scooter docking station (occupied-driving position): | |||||
| Power WC/Scooter docking station (occupied as a passenger) Please note that DORS does not pay for two power lockdown systems: | |||||
| Wheelchair Tiedown Bracket: | |||||
| Consumer's Body Restraint System (e.g. OEM, 2-point, 3-point, rigid seat belt extension, etc.) | Y | Uses OEM seatbelt | N/A | N/A | |
| Power headrest (mounting type and/or location): | |||||
| Other headrest: | |||||
| Cervical Support: | |||||
| Upper chest/torso support (indicate size): | |||||
| Torso support strap closure type: | N/A | N/A | |||
| Chest circumference in inches: | N/A | N/A | |||
| Other Restraint Equipment: | |||||
| Other Restraint Equipment: | |||||
| Other Restraint Equipment: | |||||
| 1 Year of Securement Equipment Maintenance (Parts & Labor): | Y | N/A | |||
| Totals = | $ - 0 | $ - 0 | |||
| Totals Equipment + Labor Costs = | $ - 0 | ||||
| Notes: |
Primary Driving Controls Wrksht
| DORS CS# 26-06: 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 |
| Ignition (provide manufacturer and any other specifying information): | |||||
| Quad Key Adapter: | |||||
| Electric Shift (Transmission) (provide manufactuer and any other specifying information): | |||||
| Hand Controls Type, Mode, location and any additional features: | |||||
| Electronic Gas/Brake (Indicate mounting location) (provide manufacturer and any other specifying information): | Y | Aevit L with standard roller pin mounted on the left in "reverse" mode of braking forward, accelerating back. Roller pin to the left towards door. | |||
| AVPS 2 (Auxillary Vehicle Power Supply) from EMC: | No | N/A | N/A | ||
| Secondary Battery: | |||||
| Low Effort Braking with Backup (provide manufacturer and any other specifying information): | |||||
| Zero Effort Braking with Backup (provide manufacturer and any other specifying information): | |||||
| Electric Parking Brake (provide manufacturer and any other specifying information): | |||||
| Parking Brake Extension (type and length): | |||||
| Electronic Steering (provide manufacturer and any other specifying information): | |||||
| Joystick Steering (provide manufacturer and any other specifying information): | |||||
| Steering Aid Type and Location (provide manufacturer and any other specifying information): | Y | Sure grip steering knob mounted at the 4:00 position. | |||
| Steering Wheel/Column Extension (provide manufacturer and any other specifying information): | |||||
| Different Sized Steering Wheel (indicate the Diameter): | |||||
| Reduced Effort Steering with Backup (provide manufacturer and any other specifying information): | |||||
| Zero Effort Steering with Backup (indicate counter balance weight) (provide manufacturer and any other specifying information): | |||||
| Horizontal Steering (indicate ratio) (provide manufacturer and any other specifying information): | |||||
| Electronic Left Foot Accelerator (provide manufacturer and any other specifying information): | |||||
| OEM Brake Guard (provide manufacturer and any other specifying information): | |||||
| OEM Accelerator Guard (provide manufacturer and any other specifying information): | |||||
| OEM Brake & Accelerator Guard (provide manufacturer and any other specifying information): | |||||
| Pedal Extensions Type and Length: | |||||
| Heavy Duty Battery: | Y | ||||
| Installation and removal of instructor's brake: | |||||
| Other: | Y | Custom shelf off of driver door for consumer to rest left forearm. | |||
| Other: | Y | Custom pedal guard to cover Aevit servo shroud so that consumer does not get left foot caught under Servo. Must not cover roller pin or OEM brake pedal | |||
| Other: | |||||
| Other: | |||||
| 1 Year of Primary Controls Equipment Maintenance (Parts & Labor): | Y | N/A | |||
| Totals = | $ - 0 | $ - 0 | |||
| Totals Equipment + Labor Costs = | $ - 0 | ||||
| Notes: | |||||
| End of Worksheet |
Secondary Controls Worksheet
| DORS CS# 26-06: 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 Option B secondary control package with digitone addition | |||
| Remote Secondary Control Touchscreen Location: | Y | Right side of driver | N/A | N/A | |
| Remote Secondary Control Access Method: | Y | Large 3"Jellybean switch mounted on driver door with built-out box for access with left elbow. Fitting will determine placement | |||
| Turn Signal: | Digitone to include 6 functions | N/A | N/A | ||
| Wiper Washer: | N/A | N/A | |||
| Wiper Low: | N/A | N/A | |||
| Wiper High: | N/A | N/A | |||
| Wiper Intermittent: | N/A | N/A | |||
| Horn: | N/A | N/A | |||
| Remote Headlights (high and low beam): | N/A | N/A | |||
| Dimmer | N/A | N/A | |||
| Cruise: | |||||
| Ignition: | |||||
| Remote Start: | |||||
| AC/Heat: | No | N/A | N/A | ||
| Power Windows: | |||||
| Other: | Y | EMC aux. functions to include power mirrors (3) | |||
| Other: | Y | NIDB.org Smart View mirrors to both side mirrors | |||
| Other: | |||||
| 1 Year of Secondary Control Equipment Maintenance (Parts & Labor): | Y | N/A | |||
| Totals = | $ - 0 | $ - 0 | |||
| Totals Equipment + Labor Costs = | $ - 0 | ||||
| Notes: | |||||
| End of Worksheet |
Transportation &Additional Mods
| DORS CS# 26-06: 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 | N/A | |||
| Consumer pickup and dropoff for all fittings: | Y | All fittings and final | N/A | ||
| Additional Modifications: | |||||
| Additional Modifications: | |||||
| Additional Modifications: | |||||
| Additional Modifications: | |||||
| Additional Modifications: | |||||
| Additional Modifications: | |||||
| Totals = | $ - 0 | $ - 0 | |||
| Total Equipment + Labor = | $ - 0 | ||||
| Notes: | |||||
| End of Worksheet |
Minivan Conversion Worksheet
| DORS CS# 26-06: 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 Toyota Sienna XSE, VIN: 5TDXRKEC8TS30755, Mileage: 3 | |
| Conversion Manufacturer and Conversion Type (e.g. E2, XI, XT, etc.) | Y | XI power infloor conversion | ||
| Ramp Type (e.g., In-Floor, Fold-out): | Y | In floor | ||
| Lift Type: | 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: | >54" | |||
| Interior Height at Center of Vehicle Required: | >54" | |||
| Interior Height in Driver/Passenger Position Required: | >54" | |||
| Quick release front driver seat: | No | |||
| Tie down track covers (identify location): | ||||
| Rubber Flooring to replace carpeting : | Yes | |||
| 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: | Y | |||
| Minivan Conversion Cost = | ||||
| Notes: | ||||
| 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# 26-06: 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? | Scooter Go-Go 4 wheel (80-100lbs.) |
| Make, Model & Serial Number | Go-Go Elite Traveler |
| Floor to top of head measurement | 54 1/2 |
| Eye height measurement | N/A |
| Consumer Weight | 115 |
| Width at drive wheels | 20" |
| Width at widest point | 20" |
| Tip of toes to rear most point on wheelchair when in driving position | 36" |
| Seat height w/cushion with consumer in the W/C | N/A |
| Knee height from floor to top of knees | N/A |
| Ground clearance at battery box | N/A |
| Armrest height | N/A |
| Armrest style | N/A |
| Rigid or Conventional Folding Frame | N/A |
| Power assist wheels for manual W/C. If "Yes" which manufacturer & model? | N/A |
| Removable wheels | N/A |
| Wheelchair Back Style | N/A |
| Wheelchair Back Height (Indicate what level of spine the chair back rises to (e.g.; T4-5); are there lateral supports?) | N/A |
| Wheelchair back width | N/A |
| Wheelchair Back height, folded down | N/A |
| Wheelchair folded width | N/A |
| Power Wheelchair drive system | N/A |
| Power Wheelchair Elevating Seat Feature? If "Yes" how many inches? | N/A |
| Power Positioning Components (Tilt, Recline, etc.) | N/A |
| Power Positioning Components Manufacturer | N/A |
| Power Wheelchair Weight w/Accessories | N/A |
| Foot rest type/style/removable/power | N/A |
| Wheelchair Joystick side | N/A |
| Wheelchair joystick style (e.g. fixed, articulating, hinged) | N/A |
| Headrest type (flat, soft, three section, molded, lateral control, adjustable, etc.) | N/A |
| Wheelchair headrest height measurement | N/A |
| 4-Point tie down anchors present? | N/A |
| Existing Power W/C Tie-Down Bracket? Yes/No. If "Yes" which manufacturer? | N/A |
Bid Form & Signatures
| DORS CS# 26-06: 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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File details come from the government source that posted it. Updated .