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)
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)
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
NO
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
NO
YES
NO
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
37. METHOD OF DETERMINING PRICES TO BE CHARGED TO VA
FOR DETERMINATION OF ACTUAL COSTS OF EACH ITEM FABRICATED
OR SOLD?
YES
NO
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
NO
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)

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