VA Form 2130 Inspection Sheet - Prosthetic Dealer

VA Form 2130 is a United States Department of Veterans Affairs form also known as the "Inspection Sheet - Prosthetic Dealer".

The latest fillable PDF version of the VA 2130 was issued on August 1, 1994 and can be downloaded down below or found on the Veterans Affairs Forms website.

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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
B. SATURDAY
AM TO
PM
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
9. NEAR BUS OR TROLLEY LINE
YES
NO
YES
NO
10. TYPE OF BUILDING (Check two)
11. CONDITION OF BUILDING (Check two)
BRICK
FRAME
RESIDENCE
BUSINESS BLDG.
OLD
GOOD
POOR
NEW
12. SAMPLE FINISHED PRODUCTS AVAILABLE
13. CONDITION OF SAMPLES
14. PRIVATE ROOMS FOR FITTING
YES
NO
EXCELLANT
FAIR
POOR
YES
NO
15. FITTING ROOM ACCESSIBLE TO WHEEL
16. APPROXIMATE TOTAL FLOOR SPACE OCCUPIED
17. APPROXIMATE FLOOR SPACE IN WORKSHOP
CHAIR PATIENTS
BY FIRM
ONLY
YES
NO
SQ. FT.
SQ. FT.
19. ADEQUACY AND CONDITION OF EQUIPMENT (Check two)
18. GENERAL CONDITION AND APPEARANCE OF SHOP (Check two)
CLEAN
DIRTY
NEAT
CLUTTERED
APPEARS ADEQUATE
INADEQUATE
GOOD CONDITION
POOR
20. PERSONNEL
21. FACILITIES FOR TRAINING
ITEM
NUMBERS
ITEMS
YES
NO
A. JOURNEYMAN TECHNICIANS
A. PARALLEL BARS
B. APPRENTICE TECHNICIANS
B. FULL-LENGTH MIRRORS
C. ALL OTHERS
C. RAMPS
D. TOTAL PERSONNEL (Including Manager)
D. STEPS
(
)
E. CERTIFIED PROSTHETISTS OR ORTHOTISTS
E. OTHER
F. SPECIALLY QUALIFIED PROSTHETISTS:
22. COMMENTS
(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
(
)
PART II - PRODUCTS
UNDER CENTRAL
UNDER LOCAL
NOT UNDER
*RATING OF
22. PRODUCTS FURNISHED BY DEALER
OFFICE CONTRACT
CONTRACT
CONTRACT
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
2130
AUG 1994(R)

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