VR3440B Goods and Equipment Part B: Local ...



Texas Workforce CommissionVocational Rehabilitation ServicesGoods and Equipment Part B:Local Business Location Information FORMTEXT ? For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the ESBD posting, FORMTEXT ? otherwise submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS) and FORMTEXT ? Contract Manager. FORMTEXT ?Follow instructions on the form and in the TWC VR Standards for Providers. FORMTEXT ?Type all information on form using a computer and get all required signatures. FORMTEXT ?Complete all sections of the form. Record “N/A” (not applicable) if a question does not apply. FORMTEXT ? Keep a copy of your submitted form with attachments and supporting documentation for your records. FORMTEXT ?Reason for Submission FORMTEXT ? Date of submission: FORMTEXT ????? FORMCHECKBOX Application packageSolicitation ID: FORMTEXT ????? FORMCHECKBOX Update of information due to change in information on file. FORMCHECKBOX Other. Specify: FORMTEXT ?????Parent Company Information FORMTEXT ? Parent company: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers. FORMTEXT ? FORMTEXT ?Parent company’s legal name: FORMTEXT ????? Parent company’s “doing business as” (DBA) name: FORMTEXT ?????Provide at least one of the following: FORMTEXT ?Employer Identification Number (EIN): (9 digits, issued by IRS): FORMTEXT ?????Last four digits of the sole proprietor’s Social Security Number: FORMTEXT ?????Local Business Location FORMTEXT ?Local Business: The business that part of the parent company or parent company that only operates one location or is manufacturer that provides goods and equipment to TWC-VR customers. FORMTEXT ? FORMTEXT ?Local Business Description FORMTEXT ?Local Business legal name: FORMTEXT ????? Local Business “doing business as” (DBA) name: FORMTEXT ????? Street address: FORMTEXT ?????City: FORMTEXT ?????County: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Mailing address: (if different from physical address) FORMTEXT ?????City: FORMTEXT ?????County: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Number of years in present business: FORMTEXT ?????Business Hours: FORMTEXT ?Sunday FORMTEXT ????? Monday FORMTEXT ????? Tuesday FORMTEXT ????? Wednesday FORMTEXT ?????Thursday FORMTEXT ????? Friday FORMTEXT ????? Saturday FORMTEXT ?????Business Accessibility: FORMTEXT ?A business must meet each customer’s individual accessibility needs. Note: Use the ADA Checklist for Existing Facilities, for FORMTEXT ? accessibility definitions. FORMTEXT ? FORMCHECKBOX Business does not serve customers at the business location at any time. If selected, skip remaining questions in this section.Business has accessible/handicapped parking FORMCHECKBOX Yes FORMCHECKBOX NoExterior route to enter the building is accessible (i.e. ramps, curb cuts, level) FORMCHECKBOX Yes FORMCHECKBOX NoInterior space of building used by customers is accessible (i.e. level, wheelchair seating area, elevator, wide aisles and doors) FORMCHECKBOX Yes FORMCHECKBOX NoBathroom(s) accessible FORMCHECKBOX Yes FORMCHECKBOX NoCounters at accessible height FORMCHECKBOX Yes FORMCHECKBOX NoAlarm Systems Standards FORMCHECKBOX Yes FORMCHECKBOX NoBraille signage FORMCHECKBOX Yes FORMCHECKBOX NoIf any question above is answered no, describe how the business will meet the accessibility needs of TWS customers. FORMTEXT ?????Business Safety FORMTEXT ?A business must ensure the safety of all customers by maintaining documents of proof at their location and/or physical presence of safety FORMTEXT ? equipment. Failure to answer questions below accurately could result in adverse consequences such as contract termination or the return FORMTEXT ? of funds. FORMTEXT ? FORMCHECKBOX Business does not serve customers at the business location at any time. If selected, skip remaining questions in this section.Business has local building or occupancy permit FORMCHECKBOX Yes FORMCHECKBOX NoFire inspections are in compliance with city/county requirements FORMCHECKBOX Yes FORMCHECKBOX NoBusiness has working fire extinguisher or fire sprinkler system FORMCHECKBOX Yes FORMCHECKBOX NoVisible and audible fire alarms FORMCHECKBOX Yes FORMCHECKBOX NoInterior exit signs and routes posted FORMCHECKBOX Yes FORMCHECKBOX NoPolicy and procedure for evacuation of customer during emergency FORMCHECKBOX Yes FORMCHECKBOX NoIf any question above is answered no, describe how the business will ensure the safety of TWS customers. FORMTEXT ?????Comparable Benefits the Business Accepts: FORMTEXT ? Record any insurance or funding accepted. Check all that apply. FORMTEXT ? FORMCHECKBOX Applicant or contractor is a manufacturer therefore does not accept comparable benefits. FORMCHECKBOX Aetna FORMCHECKBOX BlueCross FORMCHECKBOX Cigna FORMCHECKBOX Medicaid FORMCHECKBOX Medicare FORMCHECKBOX United Health Care FORMCHECKBOX Veteran’s Administration FORMCHECKBOX Worker’s Compensation FORMCHECKBOX None FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Staff Members FORMTEXT ?Record the name of each staff person as applicable.: FORMTEXT ?Note: Proof of qualification such as copy of license, certifications or resume with description of experience must be attached. FORMTEXT ? FORMCHECKBOX Applicant or contractor is a manufacturer therefore has no staff related to application or contract.Staff Positions: FORMTEXT ?VR Verified: FORMTEXT ? FORMCHECKBOX Assistive technology professional (ATP)Name of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX American Welding Society (AWS)Name of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX Certified Mechanic Name of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX National Mobility Equipment Dealer Association (NMEDA)Name of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX Occupational therapistName of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX PhysiatristName of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX Physical therapistName of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX PulmonologistName of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX Rehabilitation engineerName of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX Technician certified (NMEDA)Name of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Name of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Name of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Name of staff: FORMTEXT ????? FORMCHECKBOX YesInitials: FORMTEXT ?????Equipment and Goods FORMTEXT ?Select the equipment and goods your business is requesting to be included in a contract so they can be provided to TWC-VR customers when a service authorization is issued. FORMTEXT ? FORMTEXT ?Note: When the Standards for Providers requires a staff person of the business meet qualifications to provide the good or equipment, the business must have a least one person who meets the qualification(s) to have the good or equipment included in the contract. Hearing aid manufacturers do have a staff requirement. FORMTEXT ? FORMTEXT ? FORMTEXT ?Agency Use OnlyYes- indicates the SME, QASVR or RPSS verified qualification and service and can be included in the contract FORMTEXT ? FORMCHECKBOX Assistive devices for the bathroom FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX BiPAP FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Bone Anchored Hearing Aid (BAHA) Processor & Accessories FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Cochlear Implant Processor and Accessories FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX CPAP FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Hearing Aid FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Hearing Aid Accessories FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Manual wheelchairs FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Patient lifts FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Power wheelchairs FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Rehabilitation or hospital beds FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Scooters FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Seating and positioning systems FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Vehicle Modification Equipment FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Yes Initials: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Yes Initials: FORMTEXT ?????Counties FORMTEXT ? The local business can serve customers in any county included in the solicitation. FORMTEXT ?Indicate what counties the local business has the ability to provide the goods and services with a store front or has staff that can serve the customer by traveling to the customer’s location. FORMTEXT ?Manufacturers should select “All 254 Texas counties”. FORMTEXT ? FORMCHECKBOX All 254 Texas counties Vocational Rehabilitation Region 1- Borderplex Workforce Development Board FORMTEXT ? FORMCHECKBOX Brewster FORMCHECKBOX El Paso FORMCHECKBOX Hudspeth FORMCHECKBOX Jeff Davis FORMCHECKBOX Presidio FORMCHECKBOX CulbersonVocational Rehabilitation Region 1- Concho Valley Workforce Development Board FORMTEXT ? FORMCHECKBOX Coke FORMCHECKBOX Irion FORMCHECKBOX Mason FORMCHECKBOX Schleicher FORMCHECKBOX Sutton FORMCHECKBOX Concho FORMCHECKBOX Kimble FORMCHECKBOX Menard FORMCHECKBOX Sterling FORMCHECKBOX Tom Green FORMCHECKBOX Crockett FORMCHECKBOX McCulloch FORMCHECKBOX ReaganVocational Rehabilitation Region 1- North Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Archer FORMCHECKBOX Baylor FORMCHECKBOX Clay FORMCHECKBOX Cottle FORMCHECKBOX Hardeman FORMCHECKBOX Montague FORMCHECKBOX Wilbarger FORMCHECKBOX Foard FORMCHECKBOX Jack FORMCHECKBOX Wichita FORMCHECKBOX YoungVocational Rehabilitation Region 1- Panhandle Workforce Development Board FORMTEXT ? FORMCHECKBOX Armstrong FORMCHECKBOX Dallam FORMCHECKBOX Hartley FORMCHECKBOX Oldham FORMCHECKBOX Swisher FORMCHECKBOX Briscoe FORMCHECKBOX Deaf Smith FORMCHECKBOX Hemphill FORMCHECKBOX Parmer FORMCHECKBOX Wheeler FORMCHECKBOX Carson FORMCHECKBOX Donley FORMCHECKBOX Hutchinson FORMCHECKBOX Potter FORMCHECKBOX Castro FORMCHECKBOX Gray FORMCHECKBOX Lipscomb FORMCHECKBOX Randall FORMCHECKBOX Childress FORMCHECKBOX Hall FORMCHECKBOX Moore FORMCHECKBOX Roberts FORMCHECKBOX Collingsworth FORMCHECKBOX Hansford FORMCHECKBOX Ochiltree FORMCHECKBOX ShermanVocational Rehabilitation Region 1- Permian Basin Workforce Development Board FORMTEXT ? FORMCHECKBOX Andrews FORMCHECKBOX Ector FORMCHECKBOX Loving FORMCHECKBOX Pecos FORMCHECKBOX Upton FORMCHECKBOX Borden FORMCHECKBOX Gaines FORMCHECKBOX Martin FORMCHECKBOX Reeves FORMCHECKBOX Ward FORMCHECKBOX Crane FORMCHECKBOX Glasscock FORMCHECKBOX Midland FORMCHECKBOX Terrell FORMCHECKBOX Winkler FORMCHECKBOX Dawson FORMCHECKBOX HowardVocational Rehabilitation Region 1- South Plains Workforce Development Board FORMTEXT ? FORMCHECKBOX Bailey FORMCHECKBOX Dickens FORMCHECKBOX Hale FORMCHECKBOX Lamb FORMCHECKBOX Motley FORMCHECKBOX Cochran FORMCHECKBOX Floyd FORMCHECKBOX Hockley FORMCHECKBOX Lubbock FORMCHECKBOX Terry FORMCHECKBOX Crosby FORMCHECKBOX Garza FORMCHECKBOX King FORMCHECKBOX Lynn FORMCHECKBOX YoakumVocational Rehabilitation Region 1- West Texas Central Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Brown FORMCHECKBOX Eastland FORMCHECKBOX Kent FORMCHECKBOX Runnels FORMCHECKBOX Stonewall FORMCHECKBOX Callahan FORMCHECKBOX Fisher FORMCHECKBOX Knox FORMCHECKBOX Scurry FORMCHECKBOX Taylor FORMCHECKBOX Coleman FORMCHECKBOX Haskell FORMCHECKBOX Mitchell FORMCHECKBOX Shackelford FORMCHECKBOX Throckmorton FORMCHECKBOX Comanche FORMCHECKBOX Jones FORMCHECKBOX Nolan FORMCHECKBOX StephensVocational Rehabilitation Region 2- North Central Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Collin FORMCHECKBOX Erath FORMCHECKBOX Johnson FORMCHECKBOX Palo Pinto FORMCHECKBOX Somervell FORMCHECKBOX Denton FORMCHECKBOX Hood FORMCHECKBOX Kaufman FORMCHECKBOX Parker FORMCHECKBOX Wise FORMCHECKBOX Ellis FORMCHECKBOX Hunt FORMCHECKBOX Navarro FORMCHECKBOX RockwallVocational Rehabilitation Region 2- Tarrant County Workforce Development Board FORMTEXT ? FORMCHECKBOX TarrantVocational Rehabilitation Region 2- Dallas County Workforce Development Board FORMTEXT ? FORMCHECKBOX DallasVocational Rehabilitation Region 2- Texoma Workforce Development Board FORMTEXT ? FORMCHECKBOX Cooke FORMCHECKBOX Fannin FORMCHECKBOX GraysonVocational Rehabilitation Region 3- Heart of Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Bosque FORMCHECKBOX Freestone FORMCHECKBOX Hill FORMCHECKBOX Limestone FORMCHECKBOX McLennan FORMCHECKBOX FallsVocational Rehabilitation Region 3- Capital Area Workforce Development Board FORMTEXT ? FORMCHECKBOX TravisVocational Rehabilitation Region 3- Rural Capital Area Workforce Development Board FORMTEXT ? FORMCHECKBOX Bastrop FORMCHECKBOX Burnet FORMCHECKBOX Fayette FORMCHECKBOX Lee FORMCHECKBOX Williamson FORMCHECKBOX Blanco FORMCHECKBOX Caldwell FORMCHECKBOX Hays FORMCHECKBOX LlanoVocational Rehabilitation Region 3- Brazos Valley Workforce Development Board FORMTEXT ? FORMCHECKBOX Brazos FORMCHECKBOX Grimes FORMCHECKBOX Madison FORMCHECKBOX Robertson FORMCHECKBOX Washington FORMCHECKBOX Burleson FORMCHECKBOX LeonVocational Rehabilitation Region 3- Central Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Bell FORMCHECKBOX Hamilton FORMCHECKBOX Milam FORMCHECKBOX Mills FORMCHECKBOX San Saba FORMCHECKBOX Coryell FORMCHECKBOX LampasasVocational Rehabilitation Region 4- Northeast Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Bowie FORMCHECKBOX Delta FORMCHECKBOX Hopkins FORMCHECKBOX Morris FORMCHECKBOX Titus FORMCHECKBOX Cass FORMCHECKBOX Franklin FORMCHECKBOX Lamar FORMCHECKBOX Red RiverVocational Rehabilitation Region 4- East Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Anderson FORMCHECKBOX Gregg FORMCHECKBOX Marion FORMCHECKBOX Rusk FORMCHECKBOX Van Zandt FORMCHECKBOX Camp FORMCHECKBOX Harrison FORMCHECKBOX Panola FORMCHECKBOX Smith FORMCHECKBOX Wood FORMCHECKBOX Cherokee FORMCHECKBOX Henderson FORMCHECKBOX Rains FORMCHECKBOX UpshurVocational Rehabilitation Region 4- Deep East Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Angelina FORMCHECKBOX Nacogdoches FORMCHECKBOX Sabine FORMCHECKBOX San Jacinto FORMCHECKBOX Trinity FORMCHECKBOX Houston FORMCHECKBOX Newton FORMCHECKBOX San Augustine FORMCHECKBOX Shelby FORMCHECKBOX Tyler FORMCHECKBOX Jasper FORMCHECKBOX PolkVocational Rehabilitation Region 4- Southeast Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Hardin FORMCHECKBOX Jefferson FORMCHECKBOX OrangeVocational Rehabilitation Region 5- Gulf Coast Workforce Development Board FORMTEXT ? FORMCHECKBOX Austin FORMCHECKBOX Colorado FORMCHECKBOX Harris FORMCHECKBOX Montgomery FORMCHECKBOX Waller FORMCHECKBOX Brazoria FORMCHECKBOX Fort Bend FORMCHECKBOX Liberty FORMCHECKBOX Walker FORMCHECKBOX Wharton FORMCHECKBOX Chambers FORMCHECKBOX Galveston FORMCHECKBOX MatagordaVocational Rehabilitation Region 6- Golden Crescent Workforce Development Board FORMTEXT ? FORMCHECKBOX Calhoun FORMCHECKBOX Goliad FORMCHECKBOX Jackson FORMCHECKBOX Lavaca FORMCHECKBOX Victoria FORMCHECKBOX DeWitt FORMCHECKBOX GonzalesVocational Rehabilitation Region 6- Alamo Workforce Development Board FORMTEXT ? FORMCHECKBOX Atascosa FORMCHECKBOX Comal FORMCHECKBOX Guadalupe FORMCHECKBOX Kerr FORMCHECKBOX Medina FORMCHECKBOX Bandera FORMCHECKBOX Frio FORMCHECKBOX Karnes FORMCHECKBOX McMullen FORMCHECKBOX Wilson FORMCHECKBOX Bexar FORMCHECKBOX Gillespie FORMCHECKBOX KendallVocational Rehabilitation Region 6- Lower Rio Grande Valley Workforce Development Board FORMTEXT ? FORMCHECKBOX Hidalgo FORMCHECKBOX Starr FORMCHECKBOX WillacyVocational Rehabilitation Region 6- Cameron County Workforce Development Board FORMTEXT ? FORMCHECKBOX CameronVocational Rehabilitation Region 6- Middle Rio Grande Workforce Development Board FORMTEXT ? FORMCHECKBOX Dimmit FORMCHECKBOX Kinney FORMCHECKBOX Maverick FORMCHECKBOX Uvalde FORMCHECKBOX Zavala FORMCHECKBOX Edwards FORMCHECKBOX La Salle FORMCHECKBOX Real FORMCHECKBOX Val VerdeVocational Rehabilitation Region 6- Coastal Bend Workforce Development Board FORMTEXT ? FORMCHECKBOX Aransas FORMCHECKBOX Duval FORMCHECKBOX Kleberg FORMCHECKBOX Nueces FORMCHECKBOX San Patricio FORMCHECKBOX Bee FORMCHECKBOX Jim Wells FORMCHECKBOX Live Oak FORMCHECKBOX Refugio FORMCHECKBOX Brooks FORMCHECKBOX KenedyVocational Rehabilitation Region 6- South Texas Workforce Development Board FORMTEXT ? FORMCHECKBOX Jim Hogg FORMCHECKBOX Webb FORMCHECKBOX ZapataDescribe the service area if it does not include the entire county for example only within the city limits of Austin. FORMTEXT ?????Agency Use Only FORMTEXT ?SME, QASVR or RPSS verified the counties listed above are included in the solicitations and can be included in the contract. FORMCHECKBOX Yes FORMCHECKBOX No Initials: FORMTEXT ?????If no is selected, list counties that cannot be included in the contract. FORMTEXT ?????Agency Use Only FORMTEXT ?Comments, if any: Date each entry: FORMTEXT ?????Name and initials of reviewers of the application. FORMTEXT ????? ................
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