VA Form 2793 Shop Data Sheet (Artificial Limbs)

VA Form 2793 is a United States Department of Veterans Affairs form also known as the "Shop Data Sheet (artificial Limbs)".

The latest fillable PDF version of the VA 2793 was issued on March 1, 2002 and can be downloaded down below or found on the Veterans Affairs Forms website.

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

Download VA Form 2793 Shop Data Sheet (Artificial Limbs)

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