Fillable Va Form 2130 - Inspection Sheet - Prosthetic Dealer (Page 2 of 2) in pdf

Va Form 2130 - Inspection Sheet - Prosthetic Dealer Page 2

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PART III - SERVICE AND WORK RELATIONSHIP

24. IS THERE A CLINIC TEAM OPERATING IN A LOCAL VA STATION

25. IF ITEM 24 IS "YES," THEN DOES DEALER PARTICIPATE IN CLINIC SESSIONS?

SERVED BY THE DEALER?

YES

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

32. ARE PROSTHETIC SERVICE CARD INVOICES

30. ARE MOST APPLIANCES DELIVERED WITHIN

STATIONS IN EMERGENT OR DIFFICULT CASES?

NORMALLY REASONABLE AND ACCURATE?

REASONABLE TIME?

YES

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

37. METHOD OF DETERMINING PRICES TO BE CHARGED TO VA

FOR DETERMINATION OF ACTUAL COSTS OF EACH ITEM FABRICATED

OR SOLD?

YES

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?

40. LENGTH OF TIME DEALER HAS BEEN IN PROSTHETIC BUSINESS

YES

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