Exhibit A Delivery Checklist.docx
DOCX document 17 KB Posted
- Solicitation number
- 36C25625R0109
About this file
The file is a Delivery Checklist (Exhibit 1) for Durable Home Medical Equipment (DME) that provides a two-section form for documenting delivery and equipment condition. Section I requires the veteran/caregiver to confirm equipment cleanliness, proper functioning, receiving care instructions, and understanding electrical safety requirements. Section II is completed by the delivery person and verifies equipment condition, delivery instructions, handling of recovered equipment, and contact information provision. This checklist appears to be an appendix or quality control document for the related federal contract opportunity (Solicitation Number: 36C25625R0109) for DME accessories services at the Alexandria Veterans Health Care System, which is a Service-Disabled Veteran-Owned Small Business (SDVOSB) set-aside Request for Quote (RFQ) from the Department of Veterans Affairs.
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Other files
| File | Type | Posted |
|---|---|---|
| S06 - 36C25625R0109 0001.pdf | ||
| 36C25625R0109 0001_1.docx | DOCX document | |
| Exhibit B Patient Rghts and Responsibilities.docx | DOCX document | |
| Attachment 2 QASP.pdf | ||
| 36C25625R0109.pdf | ||
| Exhibit C Safety Checklist.docx | DOCX document | |
| 36C25625R0109_1.docx | DOCX document | |
| Attachment 1 PWS- Alexandria DME.pdf | ||
| Attachment 3 Conbined WDs 2015-5175 5183 5197 5209.pdf |
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Text version
DELIVERY CHECKLIST (Exhibit 1)
SECTION I- TO BE SIGNED BY VETERAN/CAREGIVER YES NO
| 1. Did items delivered appear clean? | 1. ( ) | ( ) | ||
| 2. Did equipment appear to be working properly at time delivery? | 2. ( ) | ( ) | ||
| 3. Were you given instructions in the care and mechanical use of | 3. ( ) | ( ) |
The equipment
4. You are responsible for assuring that any electrical outlets needed 4. ( ) ( ) For prescribed equipment are properly grounded and safe for such equipment. Were you informed of this requirement?
5. Were you provided with a receipt or delivery notice showing the 5. ( ) ( ) name & telephone number of the contractor in the event service or repairs are needed?
SIGNATURE OF VETERAN/CAREGIVER DATE
SECTION II-TO BE COMPLETED BY DELIVERY PERSON YES NO
| 0. Was equipment working properly at time of delivery | 1. ( ) | ( ) | |||
| 0. Were electrical cords, plugs, etc. undamaged? | 2. ( ) | ( ) | |||
| 0. Did you instruct veteran/caregiver in the proper care and | 3. ( ) | ( ) |
Mechanical use of delivered equipment?
0. If veteran/caregiver had questions about equipment which 4. ( ) ( ) you could not answer, did you contact either the contractor or Prosthetics personnel?
0. Did you provide a receipt or delivery notice showing 5. ( ) ( ) Contractor’s name and telephone number?
0. If recovered equipment was picked up during this or a prior 6. ( ) ( ) 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
File details come from the government source that posted it. Updated .