Delivery Checklist.docx

DELIVERY CHECKLIST

Veteran's Name: SS#: _

SECTION I - TO BE SIGNED BY VETERAN/CAREGIVER YES NO

1. Did items delivered appear clean? ( ) ( )

2. Did equipment appear to be working properly at time of delivery? ( ) ( )

3. Were you given instructions in the care and ( ) ( ) mechanical use of the equipment?

4. You are responsible for assuring that any electrical ( ) ( ) outlets needed for prescribed equipment are properly grounded and safe for such equipment. Were you informed of this requirement prior to delivery?

5. Were you provided with a receipt or delivery notice ( ) ( ) showing the name & telephone number of the contractor in the event service or repairs are needed. ( ) ( )

SIGNATURE OF VETERAN/CAREGIVER DATE

SECTION II - TO BE COMPL ETED BY DELIVERY PERSON

1. Was equipment working properly at time of delivery?

2. Were electrical cords, plugs, etc. undamaged?

3. Did you instruct veteran/caregiver in the proper care and mechanical use of delivered equipment?

4. If veteran/caregiver had questions about equipment which you could not answer, did you contact either the contractor or Prosthetics personnel?

5. Did you provide a receipt or delivery notice showing Contractor’s name and telephone number?

6. If recovered equipment was picked-up during this or a prior delivery this day, did you segregate such equipment from new/cleaned items and use prescribed precautions for handling such equipment?

SIGNATURE OF DELIVERY PERSON DATE