Exhibit A - Delivery Checklist.pdf
PDF 131 KB Posted
- Attached to
- DME Services Federal contract opportunity
- Solicitation number
- 36C25624Q1457
About this file
This document is a Delivery Checklist that is part of a federal contract opportunity. The Delivery Checklist outlines the items that must be verified by both the veteran/caregiver and the delivery person during the delivery of durable medical equipment (DME). Key details include:
The Delivery Checklist has two sections - Section I to be signed by the veteran/caregiver, and Section II to be completed by the delivery person. The checklist verifies items such as the equipment's cleanliness and proper functioning, instructions provided to the veteran/caregiver, and safety of electrical outlets. The delivery person also indicates whether they provided a receipt with contractor contact information.
The related federal contract opportunity is a Request for Quotation (RFQ) for DME contract services, issued as a total Service-Disabled Veteran-Owned Small Business (SDVOSB) set-aside. The North American Industry Classification System (NAICS) code is 621610 with a $19 million small business size standard. Contractor registration in the System for Award Management (SAM) and with the Small Business Administration (SBA) is required.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| 36C25624Q1457 0001 DME 12052024.pdf | ||
| Attachment 6 Bay County FL WD 2015-4559 R25 dtd 05-07-2024.pdf | ||
| Attachment 5 Mobile County AL WD 2015-4605 R22 dtd 05-08-2024.pdf | ||
| Attachment 3 Escambia County FL WD 2015-4561 R25 dtd 05-07-2024.pdf | ||
| Attachment 2 - Quality Assurance Surveillance Plan.pdf | ||
| Attachment 1 DME PWS Template 09032024.docx | DOCX document | |
| 36C25624Q1457 DME.docx | DOCX document | |
| Exhibit C - Safety Checklist.pdf | ||
| Attachment 4 Harrison County MS WD 2015-5147 R23 dtd 04-20-2024.pdf | ||
| Exhibit B - Patient Rights and Responsibilities.pdf |
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Text version
Exhibit A
A-1
DELIVERY CHECKLIST
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
1. Was equipment working properly at time of delivery 1. ( ) ( )
2. Were electrical cords, plugs, etc. undamaged? 2. ( ) ( )
3. Did you instruct veteran/caregiver in the proper care and 3. ( ) ( )
Mechanical use of delivered equipment?
4. If veteran/caregiver had questions about equipment which 4. ( ) ( ) you could not answer, did you contact either the contractor or Prosthetics personnel?
5. Did you provide a receipt or delivery notice showing 5. ( ) ( ) Contractor’s name and telephone number?
6. 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 .