Free VA Form VA2793 - Shop Data Sheet (Artificial Limbs) - Federal

SHOP DATA SHEET (ARTIFICIAL LIMBS)
NOTE: This form must be accurately completed and submitted by the bidder, in duplicate for each shop owned and operated by said bidder and for all branch shops and/or shops of bidder's agents at which service will be performed under this contract. The data submitted on this form will be checked for accuracy by the Department of Veterans Affairs. (If space below is not sufficient, please continue information on a separate sheet of paper and attach.) The information requested on this form is solicited under authority of Title 38, "Veterans Benefits", and will be used to assist us in evaluating your facility. It will not be used for any other purpose. Disclosure is voluntary. However, failure to furnish this information will result in delaying the bidding process. It will have no adverse effect on any other benefits to which you may be entitled.
1. NAME OF BIDDER 1A. FULL BUSINESS NAME OF SHOP (If other than item 1)

2. COMPLETE ADDRESS OF SHOP

3. TRADE NAME (If any)

4. DAYS OF BUSINESS
THROUGH

5. HOURS OF BUSINESS
A.M. TO P.M.

NOTE: Firms which have previously held contracts with the Department of Veterans Affairs DO NOT need to fill out Item 6 through Item 11, unless changes have ocurred.
6. NO. OF YEARS EXPERI- 7. NO. OF YEARS EXPERI- 8. DOES YOUR SHOP 8A. IF "NO" IS CHECKED IN ITEM 8, GIVE NAME ENCE IN ARTIFICIAL ENCE IN ARTIFICIAL USUALLY MAKE ITS AND ADDRESS OF YOUR PRINCIPAL LIMB BUSINESS AT LIMB BUSINESS AT OWN "SET-UPS?" SUPPLIER PRESENT ADDRESS OTHER LOCATIONS YES NO 9. IS IT COMMON PRACTICE TO REQUIRE A PHYSICIAN'S PRESCRIPTION AS A CONDITION FOR FITTING OF CIVILIAN AMPUTEES? YES NO

10. IF YOUR FIRM HAS BEEN IN BUSINESS LESS THAN 3 YEARS, LIST TWO BUSINESS REFERENCES (Including bank reference)
A. NAME AND LOCATION OF ORGANIZATION B. NAME AND LOCATION OF ORGANIZATION

11. GIVE NAMES AND ADDRESSES OF CIVILIAN PHYSICIANS WHO HAVE REFERRED PATIENTS TO YOUR SHOP
A. NAME AND OFFICE ADDRESS B. NAME AND OFFICE ADDRESS C. NAME AND OFFICE ADDRESS

12. TOTAL NUMBER OF 13. NO. OF EMPLOYEES EMPLOYEES IN THE ENGAGED IN THE SHOP (Including officials) FABRICATION OF LIMBS

14. NO. OF FULL-TIME 15. NO. OF PROSTHETISTS EMPLOYED WHO HAVE SUCCESSFULLY COMPLETED QUALIFIED LIMB ONE OR MORE OF THE FOLLOWING POST-GRADUATE COURSE IN PROSTHETICS FITTERS (If none, then write "none") EMPLOYED B. A/K PROSTHETICS C. OTHER (Specify) A. UPPER EXTREMITY COURSE COURSE

16. NAMES AND CERTIFICATE NUMBERS OF CERTIFIED SUCTION SOCKET FITTERS (If none, then write "none")
A. NAME CERTIFICATE NUMBER B. NAME CERTIFICATE NUMBER

18A. IF ITEM 18 IS "NO," ARE ELEVATORS 18. IS FITTING ROOM ON GROUND OFFICE OTHER AVAILABLE FLOOR YES YES NO NO (Specify) BUILDING 20. TOTAL FLOOR SPACE IN WORK- 21. TOTAL FLOOR SPACE IN FITTING ROOM 22. TOTAL OFFICE FLOOR SPACE 19. TOTAL FLOOR SPACE OCCUPIED SHOP BY SHOP SQ. FT. SQ. FT. SQ. FT. SQ. FT. 17. SHOP LOCATED IN PRIVATE RESIDENCE 23. IS SHOP EQUIPPED WITH PARALLEL BARS FOR WALKING TRAINING? YES ITEM NO NUMBER TYPE 24. IS SHOP EQUIPPED WITH FULL-LENGTH 25. IS SHOP EQUIPPED WITH RAMPS? MIRRORS? YES NO YES NO ITEM NUMBER TYPE

26. INDICATE NUMBER AND TYPE OF SHOP EQUIPMENT (Use reverse side for equipment not listed) A. BAND SAW B. SANDING DISC C. SANDING PAPER D. FLEXIBLE SHAFT SANDER E. LATHE (WOOD-TURNING) F. DRILL PRESS CERTIFICATION: I do hereby certify that the above statements are true and correct to the best of my knowledge and belief.
VA Form MAR 2002(RS) SIGNATURE AND TITLE

G. SEWING MACHINE H. GRINDING EQUIPMENT I. PAINT-SPRAYING EQUIPMENT J. WELDING EQUIPMENT K. ALIGNMENT JIG O. OTHER (Specify)
DATE

2793

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CONTINUATION SHEET (Use this space for all data fields that are too small to capture desired text entry)

VA FORM 2793, MAR 2002(RS), PAGE 2

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