Fillable Printable VA Form 2130
Fillable Printable VA Form 2130
VA Form 2130
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)
4. BUSINESS HOURS
A. MONDAY THROUGH FRIDAY
AM TO PM
B. SATURDAY
AM TO PM
5. CURRENT CENTRAL OFFICE CONTRACT NUMBERS
6. CURRENT LOCAL CONTRACT NUMBERS
PART I - DESCRIPTION OF PHYSICAL FACILITIES AND PERSONNEL
7. DISTANCE FROM LOCAL VA STATION 8. ADEQUATE PARKING FACILITIES
YES NO
9. NEAR BUS OR TROLLEY LINE
YES NO
10. TYPE OF BUILDING (Check two)
BRICK FRAME
RESIDENCE BUSINESS BLDG.
11. CONDITION OF BUILDING (Check two)
NEW
OLD
GOOD POOR
12. SAMPLE FINISHED PRODUCTS AVAILABLE
YES NO
13. CONDITION OF SAMPLES
EXCELLANT
FAIR POOR
14. PRIVATE ROOMS FOR FITTING
YES NO
15. FITTING ROOM ACCESSIBLE TO WHEEL
CHAIR PATIENTS
YES NO
16. APPROXIMATE TOTAL FLOOR SPACE OCCUPIED
BY FIRM
SQ. FT.
17. APPROXIMATE FLOOR SPACE IN WORKSHOP
ONLY
SQ. FT.
18. GENERAL CONDITION AND APPEARANCE OF SHOP (Check two)
CLEAN DIRTY NEAT CLUTTERED
19. ADEQUACY AND CONDITION OF EQUIPMENT (Check two)
APPEARS ADEQUATE
INADEQUATE
GOOD CONDITION POOR
20. PERSONNEL
ITEM
A. JOURNEYMAN TECHNICIANS
NUMBERS
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
(
)
(
)
21. FACILITIES FOR TRAINING
ITEMS
A. PARALLEL BARS
YES NO
B. FULL-LENGTH MIRRORS
C. RAMPS
D. STEPS
E. OTHER
22. COMMENTS
PART II - PRODUCTS
22. PRODUCTS FURNISHED BY DEALER
UNDER CENTRAL
OFFICE CONTRACT
UNDER LOCAL
CONTRACT
NOT UNDER
CONTRACT
*RATING OF
FINISHED PRODUCTS
A. ARTIFICIAL LEGS
B. ARTIFICIAL ARMS
C. BRACES
D. BELTS AND TRUSSES
E. ELASTIC HOSE
F. ORTHOPEDIC SHOES
G.
H.
* 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
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)
30. ARE MOST APPLIANCES DELIVERED WITHIN
REASONABLE TIME?
YES NO
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
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)
36. DOES DEALER MAINTAIN ADEQUATE COST - ACCOUNTING SYSTEM
FOR DETERMINATION OF ACTUAL COSTS OF EACH ITEM FABRICATED
OR SOLD?
YES NO
37. METHOD OF DETERMINING PRICES TO BE CHARGED TO VA
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 SUPERIOR ABOVE AVG. AVERAGE POOR *POINTS
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
*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)
