Free VA Form VA2130 - Inspection Sheet - Prosthetic Dealer - Federal

INSPECTION SHEET - PROSTHETIC DEALER
1. NAME OF COMPANY 2. ADDRESS (Street, City, State and ZIP Code)

3. NAME AND TITLE OF PRINCIPAL EXECUTIVE (Owner or Manager) AM TO 5. CURRENT CENTRAL OFFICE CONTRACT NUMBERS

4. BUSINESS HOURS
A. MONDAY THROUGH FRIDAY PM B. SATURDAY AM TO PM

6. CURRENT LOCAL CONTRACT NUMBERS

PART I - DESCRIPTION OF PHYSICAL FACILITIES AND PERSONNEL
7. DISTANCE FROM LOCAL VA STATION 10. TYPE OF BUILDING (Check two) BRICK YES NO FRAME RESIDENCE BUSINESS BLDG. EXCELLANT 12. SAMPLE FINISHED PRODUCTS AVAILABLE 15. FITTING ROOM ACCESSIBLE TO WHEEL CHAIR PATIENTS YES CLEAN NO DIRTY NEAT CLUTTERED 8. ADEQUATE PARKING FACILITIES YES NO NEW FAIR OLD POOR 9. NEAR BUS OR TROLLEY LINE YES 11. CONDITION OF BUILDING (Check two) GOOD YES POOR NO 13. CONDITION OF SAMPLES 16. APPROXIMATE TOTAL FLOOR SPACE OCCUPIED BY FIRM 14. PRIVATE ROOMS FOR FITTING 17. APPROXIMATE FLOOR SPACE IN WORKSHOP ONLY SQ. FT. POOR NO

18. GENERAL CONDITION AND APPEARANCE OF SHOP (Check two)

SQ. FT. 19. ADEQUACY AND CONDITION OF EQUIPMENT (Check two) APPEARS ADEQUATE INADEQUATE GOOD CONDITION

20. PERSONNEL
ITEM A. JOURNEYMAN TECHNICIANS B. APPRENTICE TECHNICIANS C. ALL OTHERS D. TOTAL PERSONNEL (Including Manager) E. CERTIFIED PROSTHETISTS OR ORTHOTISTS F. SPECIALLY QUALIFIED PROSTHETISTS: (1) STANDARD PTB BELOW KNEE LEGS (2) SPECIAL SOCKETS FOR PTB LEGS (Variants) (3) TOTAL CONTACT AK SOCKETS (4) ALL FLUID CONTROL LEGS (5) HYDRA - CADENCE FLUID CONTROL ONLY (6) IMMEDIATE POST SURGICAL OR EARLY FITTING SERVICE (7) OTHER NUMBERS

21. FACILITIES FOR TRAINING
ITEMS A. PARALLEL BARS B. FULL-LENGTH MIRRORS C. RAMPS D. STEPS YES NO

( ( ( ( ( ( ( ( (

) E. OTHER ) 22. COMMENTS ) ) ) ) ) ) ) UNDER LOCAL CONTRACT NOT UNDER CONTRACT *RATING OF FINISHED PRODUCTS

PART II - PRODUCTS
PRODUCTS FURNISHED BY DEALER
A. ARTIFICIAL LEGS B. ARTIFICIAL ARMS C. BRACES D. BELTS AND TRUSSES E. ELASTIC HOSE F. ORTHOPEDIC SHOES G. H.

UNDER CENTRAL OFFICE CONTRACT

*Should be based upon combination of your own evaluation and general experience of local field stations. Use standard rating terms outlined in Part IV, back of form. Explain all "POOR" ratings in item 23 below.
23. EXPLANATION OR REMARKS

VA FORM AUG 1994(R)

2130

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PART III - SERVICE AND WORK RELATIONSHIP
24. IS THERE A CLINIC TEAM OPERATING IN A LOCAL VA STATION SERVED BY THE DEALER? YES NO 25. IF ITEM 24 IS "YES," THEN DOES DEALER PARTICIPATE IN CLINIC SESSIONS? REGULARLY OCCASIONALLY NEVER

26. IF DEALER PARTICIPATES IN CLINIC SESSIONS, WHAT IS THEIR HONEST OPINION OF THE CLINIC TEAM?

27. IF DEALER DOES NOT PARTICIPATE IN CLINIC SESSIONS, WHAT REASONS DO THEY GIVE?

28. IS THERE EVIDENCE OF FRICTION BETWEEN THIS DEALER AND PERSONNEL IN LOCAL VA STATIONS? YES NO (If "YES," describe difficulty)

29. IS THERE EVIDENCE OF EXCESSIVE COMPLAINTS FROM VETERANS AGAINST THIS DEALER? YES NO (If "YES," explain) 31. DOES DEALER COOPERATE FULLY WITH LOCAL VA STATIONS IN EMERGENT OR DIFFICULT CASES? YES NO 32. ARE PROSTHETIC SERVICE CARD INVOICES NORMALLY REASONABLE AND ACCURATE? YES NO

30. ARE MOST APPLIANCES DELIVERED WITHIN REASONABLE TIME? YES NO

33. REMARKS (Explain "NO," answers to 30 through 32, above. List any complaints of dealer against VA)

PART IV - SPECIAL INFORMATION AND GENERAL EVALUATION
34. IS DEALER CONDUCTING SPECIFIC RESEARCH OR DEVELOPMENT ON PROSTHETIC DEVICES? YES NO (If "YES," describe briefly)

35. DOES DEALER PRODUCE DEVICES OF THEIR OWN DESIGN NOT AVAILABLE ELSEWHERE? YES NO (If "YES," describe briefly) 37. METHOD OF DETERMINING PRICES TO BE CHARGED TO VA

36. DOES DEALER MAINTAIN ADEQUATE COST - ACCOUNTING SYSTEM FOR DETERMINATION OF ACTUAL COSTS OF EACH ITEM FABRICATED OR SOLD? YES NO

38. APPROXIMATE PERCENTAGE OF DEALERS' TOTAL ANNUAL DOLLAR SALES MADE TO DEPARTMENT OF VETERANS AFFAIRS LESS THAN 10% 10% TO 25% 25% TO 50% 50% TO 75% OVER 75% 39. DOES COMPANY CLAIM CERTIFICATION BY AMERICAN BOARD? YES NO 40. LENGTH OF TIME DEALER HAS BEEN IN PROSTHETIC BUSINESS

YEARS

MONTHS

41. GENERAL EVALUATION
Based upon your inspection of this dealers facilities and products; the opinions expressed Physicians and Prosthetic Personnel in local VA stations; and any other knowledge you may have concerning the company or its services, check your overall rating for each of the elements below. ELEMENTS
A. WORKMANSHIP, FIT AND ALIGNMENT OF APPLIANCES B. QUALITY OF MATERIALS USED IN FABRICATION C. COMPARATIVE USEFUL LIFE OF APPLIANCES D. PROMPTNESS OF DELIVERY E. QUALITY AND PROMPTNESS OF SERVICES AND REPAIRS F. COOPERATIVENESS WITH VA AND VETERANS SERVED G. ADEQUACY OF EQUIPMENT AND PERSONNEL H. CLEANLINESS AND ACCESSIBILITY OF SHOP I. GENERAL OVERALL EVALUATION OF COMPANY

SUPERIOR

ABOVE AVG.

AVERAGE

POOR

*POINTS

*FOR CENTRAL OFFICE USE ONLY.
42. GENERAL REMARKS (If additional space is required, attach additional sheet.)

43. SIGNATURE AND TITLE OF REPORTING OFFICIAL

44. DATE OF INSPECTION

45. DATE OF REPORT

BACK OF VA FORM 2130, AUG 1994 (R)

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