Fillable Printable VA Form 2793
Fillable Printable VA Form 2793
VA Form 2793
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-
ENCE IN ARTIFICIAL
LIMB BUSINESS AT
PRESENT ADDRESS
7. NO. OF YEARS EXPERI-
ENCE IN ARTIFICIAL
LIMB BUSINESS AT
OTHER LOCATIONS
8. DOES YOUR SHOP
USUALLY MAKE ITS
OWN "SET-UPS?"
YES NO
8A. IF "NO" IS CHECKED IN ITEM 8, GIVE NAME
AND ADDRESS OF YOUR PRINCIPAL
SUPPLIER
9. IS IT COMMON PRACTICE TO
REQUIRE A PHYSICIAN'S PRE-
SCRIPTION 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
EMPLOYEES IN THE
SHOP (Including officials)
13. NO. OF EMPLOYEES
ENGAGED IN THE
FABRICATION OF
LIMBS
14. NO. OF FULL-TIME
QUALIFIED LIMB
FITTERS
EMPLOYED
15. NO. OF PROSTHETISTS EMPLOYED WHO HAVE SUCCESSFULLY COMPLETED
ONE OR MORE OF THE FOLLOWING POST-GRADUATE COURSE IN PROSTHETICS
(If none, then write "none")
A. UPPER EXTREMITY
COURSE
B. A/K PROSTHETICS
COURSE
C. OTHER (Specify)
16. NAMES AND CERTIFICATE NUMBERS OF CERTIFIED SUCTION SOCKET FITTERS (If none, then write "none")
A. NAME CERTIFICATE NUMBER B. NAME CERTIFICATE NUMBER
17. SHOP LOCATED IN
PRIVATE RESIDENCE
OFFICE
BUILDING
OTHER
(Specify)
18. IS FITTING ROOM ON GROUND
FLOOR
YES
NO
18A. IF ITEM 18 IS "NO," ARE ELEVATORS
AVAILABLE
YES NO
19. TOTAL FLOOR SPACE OCCUPIED
BY SHOP
SQ. FT.
20. TOTAL FLOOR SPACE IN WORK-
SHOP
SQ. FT.
21. TOTAL FLOOR SPACE IN FITTING ROOM
SQ. FT.
22. TOTAL OFFICE FLOOR SPACE
SQ. FT.
23. IS SHOP EQUIPPED WITH PARALLEL BARS FOR WALKING TRAINING?
YES NO
24. IS SHOP EQUIPPED WITH FULL-LENGTH
MIRRORS?
YES NO
25. IS SHOP EQUIPPED WITH RAMPS?
YES
NO
26. INDICATE NUMBER AND TYPE OF SHOP EQUIPMENT (Use reverse side for equipment not listed)
ITEM NUMBER TYPE
A. BAND SAW
B. SANDING DISC
C. SANDING PAPER
D. FLEXIBLE
SHAFT SANDER
E. LATHE
(WOOD-TURNING)
F. DRILL PRESS
ITEM NUMBER TYPE
G. SEWING MACHINE
H. GRINDING EQUIPMENT
I. PAINT-SPRAYING
EQUIPMENT
J. WELDING EQUIPMENT
K. ALIGNMENT JIG
O. OTHER (Specify)
CERTIFICATION: I do hereby certify that the
above statements are true and correct to the best
of my knowledge and belief.
SIGNATURE AND TITLE DATE
VA FORM
MAR 2002(RS)
2793
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
