N. Antlitz ROF VEAPA CS# 25-24_REVISED.xlsx
XLSX spreadsheet 459 KB Posted
- Attached to
- Vehicle Modification CS#25-24
- Solicitation number
- BPM054513
- Issued by
- Maryland
About this file
This is a Vehicle Equipment Adaptation Prescription Agreement (VEAPA) and bid form workbook prepared by the Maryland State Department of Education Division of Rehabilitation Services (DORS) for vehicle modification services. The project involves the supply and installation of adaptive equipment and modifications to a 2025 GMC Sierra 1500 for a DORS consumer with a C6-C7 spinal cord injury. The modifications include an ATC passenger-side conversion with front entry automatic lift, primary driving controls (hand controls, electronic gas/brake system, Tripin steering aid, and quad key adapter), securement and restraint systems (QLK-150 wheelchair restraint system and upper torso support), and vehicle transport with consumer pickup and dropoff services. The contract term is anticipated to begin on or about January 12, 2026, and expire July 12, 2026. Bidders must submit pricing for equipment costs and labor costs in the Excel workbook, with all calculations automatically totaled by the system. The bid form must be signed and dated by an authorized representative and submitted through the DORS Invoice and Reports Portal.
All bidders must be certified by the National Mobility Equipment Dealers Association (NMEDA) Quality Assurance Program (QAP) to be eligible for award. Quotations and bids are firm and must be guaranteed for 120 days after the due date, with authorization to begin work permitted within a 90-day period. The vendor is responsible for ensuring all modifications comply with Federal Motor Vehicle Safety Standards (FMVSS) and NMEDA standards, providing full manufacturer warranties, and completing a final fitting and checkout with the consumer, mobility dealer technician, and driving rehabilitation specialist present. The vendor must provide detailed communication updates to DORS at specific project milestones, coordinate scheduling with the Certified Driver Rehabilitation Specialist, and submit required documentation including NHTSA "Make Inoperable" disclosure forms, warranty documents, and consumer-signed final receipt and agreement forms upon project completion.
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Text version
Workbook&Bid Form Instructions DORS CS# 25-24: 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# 25-24: 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# 25-24: 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# 25-24: 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 |
| Maryland State Department of Education |
Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form) Maryland State Department of Education Division of Rehabilitation Services Vehicle Equipment Adaptation Prescription and Agreement (VEAPA and Bid Form)
| Certified Driving Rehabilitation Specialist (CDRS) Name and Credentials: | Timothy Jones OTR, CDRS, CDI |
| Date of VEAPA: | 3/24/25 |
| Consumer Information: | |
| Consumer's First Initial & Last Name: | N. Antlitz |
| Participant ID#: | 179663 |
| Address (Town, State only): | Bowie, Maryland |
| Disability/Functional Limitations related to driving: | C6-C7 SCI |
| Purpose for Driving/Vehicle Modifications: | Employment/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. Wheelchair |
| If Consumer Uses a W/C; Is it Manual or Powered? | Manual |
| If Consumer Uses a Wheelchair or Scooter, See "Wheelchair/Scooter Worksheet" Tab of this Workbook. | |
| Consumer's Weight: | 175 |
| If in Wheelchair; height from floor to top of head: | 52" |
| Consumer can transfer to OEM vehicle seat independently: | Can perform a lateral transfer |
| Does consumer use a transfer aid? If so; what type: | No |
| Consumer can use a swivel transfer seat: | No |
| List any Drivers' License restrictions: | Hand controls, Tripin, Chest strap |
| List any Learners' Permit Restrictions: | |
| DORS Field Counselor Name: | Gene Walp |
| DORS Field Counselor Phone Number: | 410-974-7741 |
| Vehicle Information | |
| After Approvals have been obtained and the Vehicle is purchased by consumer; list the Make, Model, Year and Mileage, VIN: | 2025 GMC Sierra 1500, 7 miles, VIN: 3GTUUCE89SG395722 |
| Vehicle purchased by consumer (VIN#): | Pending |
| End of Worksheet |
Wheelchair-Scooter Stowage
| VEAPA-Wheelchair/Scooter Stowage Equipment Worksheet |
| Maryland State Department of Education |
Vehicle Equipment Adaptation Prescription and Agreement (VEAPA) and Bid Form
| DORS CS# 25-24 | |||||
| ATTACHMENT B | |||||
| 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: | Y | ||||
| Totals = | $ - 0 | $ - 0 | |||
| Total Equipment + Labor = | $ - 0 | ||||
| Notes: |
Securement-Restraint Sys Wrksht
| DORS CS# 25-24 : 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: | |||||
| Power driver transfer seat switch box location: | N/A | N/A | |||
| Power driver transfer seat handheld remote: | N/A | N/A | |||
| Power driver transfer seat override switch location: | N/A | N/A | |||
| Power turning seat to get in and out of the vehicle: | |||||
| Manual Wheelchair (WC) Restraint System (Do not specify here if already included on the Braun Conversion: | Y | QLK-150 for Tilite ZRA Bracket Q04BR133 in passenger station of truck | |||
| Manual WC Restraint System Location: | Y | Front passenger station | N/A | N/A | |
| Power WC/Scooter docking station (unoccupied-consumer in drivers' seat): | |||||
| 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 | Using OEM belt | |||
| Power headrest (mounting type and/or location): | |||||
| Other headrest: | |||||
| Cervical Support: | |||||
| Upper chest/torso support (indicate size): | Y | Large universal Nutec with Type II closure | |||
| Torso support strap closure type: | Y | Type II | N/A | N/A | |
| Chest circumference in inches: | Y | 40" | N/A | N/A | |
| Other Restraint Equipment: | |||||
| Other Restraint Equipment: | |||||
| Other Restraint Equipment: | |||||
| 1 Year of Securement Equipment Maintenance: | Y | ||||
| Totals = | $ - 0 | $ - 0 | |||
| Totals Equipment + Labor Costs = | $ - 0 | ||||
| Notes: |
Primary Driving Controls Wrksht
| DORS CS# 25-24: 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: | Y | Sure Grip push rock featherlight mounted on the left. | |||
| Electronic Gas/Brake (Indicate mounting location) (provide manufacturer and any other specifying information): | |||||
| AVPS 2 (Auxillary Vehicle Power Supply) from EMC: | |||||
| 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 | Tripin mounted at the 4:00 position | |||
| Steering Wheel/Column Extension (provide manufacturer and any other specifying information): | |||||
| Steering Wheel 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: | |||||
| Installation and removal of instructor's brake: | |||||
| Other: | |||||
| Other: | |||||
| Other: | |||||
| Other: | |||||
| 1 Year of Primary Controls Equipment Maintenance: | Y | ||||
| Totals = | $ - 0 | $ - 0 | |||
| Totals Equipment + Labor Costs = | $ - 0 | ||||
| Notes: | |||||
| End of Worksheet |
Secondary Controls Worksheet
| VEAPA-Secondary Controls Specifications/Prescription Worksheet |
| Maryland State Department of Education |
| DORS CS# 25-24 | |||||
| ATTACHMENT B | |||||
| Modification Type | Existing | Needed | Equipment Description and/or Instructions | Equipment Cost | Labor Cost |
| Remote Secondary Control Package (provide manufacturer and any other specifying information): | |||||
| Remote Secondary Control Touchscreen Location: | N/A | N/A | |||
| Remote Secondary Control Access Method: | |||||
| Turn Signal: | 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: | |||||
| Power Windows: | |||||
| Other: | |||||
| Other: | |||||
| Other: | |||||
| 1 Year of Secondary Control Equipment Maintenance: | Y | ||||
| Totals = | $ - 0 | $ - 0 | |||
| Totals Equipment + Labor Costs = | $ - 0 | ||||
| Notes: | |||||
| End of Worksheet |
Transportation &Additional Mods
| DORS CS# 25-24: 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 | Bowie, MD | N/A | ||
| Consumer pickup and dropoff for all fittings: | Y | Bowie, MD | 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
| VEAPA-Minivan Conversion Specs Worksheet |
| Maryland State Department of Education |
| DORS CS# 25-24 | ||||
| ATTACHMENT B | ||||
| 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 | ||
| Conversion Manufacturer and Conversion Type (e.g. E2, XI, XT, etc.) | ||||
| Ramp Type (e.g., In-Floor, Fold-out): | ||||
| Lift Type: | ||||
| Transmission Type (e.g., Automatic, 2-Wheel Drive, All Wheel Drive ) | ||||
| Lowered Floor cut location (e.g. rear axle to firewall): | ||||
| Door Opening Height Required: | ||||
| Interior Height at Center of Vehicle Required: | ||||
| Interior Height in Driver/Passenger Position Required: | ||||
| Quick release front driver seat: | ||||
| Tie down track covers: | ||||
| Rubber Flooring to replace carpeting : | ||||
| 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
| VEAPA-Full Size Van/Truck Conversion Specs Worksheet |
| Maryland State Department of Education |
| DORS CS# 25-24 |
| DORS CS# 25-24 : 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: | Y | 2025 GMC Sierra 1500, 7 miles, VIN: 3GTUUCE89SG395722 | |
| Conversion Manufacturer and Conversion Type (e.g. E2, XI, XT, etc.) | Y | ATC passenger conversion | |
| Entry Type: Side, Front, Rear: | Y | Front passenger | |
| Entry Side (Driver or Passenger): | Y | Passenger | |
| Lift Type: | Y | Automatic | |
| Transmission Type (e.g., Automatic, 2-Wheel Drive, All Wheel Drive ) | Y | 4 wheel drive | |
| Lowered Floor cut location (e.g. center section, center & driver, center & passenger, full:center, driver & passenger): | Y | Passenger side of truck | |
| Door Opening Height Required: | Y | >52" | |
| Interior Height at Center of Vehicle Required: | Y | >52" | |
| Interior Height at Driver/Passenger Position Required: | Y | >52" | |
| Quick release front driver seat: | No | ||
| Quick release front passenger seat (give justification if recommending both driver and passenger side quick release feature) | Y | This is a passenger application who will transfer across bench seat to drive. Front passenger seat must be replacable. | |
| Wheelchair tie down tracks location: | N/A | ||
| Tie Down Track Covers: | N/A | ||
| Wheelchair stowage method and location: | Y | Will transfer out of manual wheelchair and slide across bench seat into driver station. Chair will be secured with power tie down | |
| 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): | Y | ATC conversion standard package-passenger conversion | |
| 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: | 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
| Wheelchair (W/C)/Scooter Specifications Worksheet |
| DORS CS# 25-24: 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? | Manual |
| Make, Model & Serial Number | Tilite ZRA |
| Floor to top of head measurement | 52" |
| Eye height measurement | 47 1/2" |
| Consumer Weight | 175 |
| Width at drive wheels | 24" |
| Width at widest point | 24" |
| Tip of toes to rear most point on wheelchair when in driving position | 35" |
| Seat height w/cushion with consumer in the W/C | N/A |
| Knee height from floor to top of knees | 24" |
| Ground clearance at battery box | N/A |
| Armrest height | N/A |
| Armrest style | N/A |
| Rigid or Conventional Folding Frame | Rigid |
| Power assist wheels for manual W/C. If "Yes" which manufacturer & model? | N/A |
| Removable wheels | Yes |
| Wheelchair Back Style | ADI back |
| Wheelchair Back Height (Indicate what level of spine the chair back rises to (e.g.; T4-5); are there lateral supports?) | Low thoracic |
| Wheelchair back width | 14" |
| 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? | No |
| Existing Power W/C Tie-Down Bracket? Yes/No. If "Yes" which manufacturer? | No |
Bid Form & Signatures
| DORS CS# 25-24: 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 | ||||
| Conversion other than Minivan 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 .