Page Revision Date
12/23/2002
NMEDA QAP
Manual Page 26
Appendix L - NMEDA Label Reporting Form
Reporting Year/Month: _______/_____ |
For RADCO Use Only Dealer Client Number: |
Dealer: |
Columbus Mobility Specialists, Inc. |
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Address: |
6330 Proprietors Road, Suite C |
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City, State, Zip Code: |
Worthington, Ohio 43085 |
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Representative |
________________________________________________________ |
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Customer Name |
________________________________________________________ |
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Address |
________________________________________________________ |
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Vehicle Make & Model |
Vehicle Identification Number |
NMEDA Label# |
Completion Date |
|
_____________________ |
_________________________ |
________________ |
______________ |
|
1. Steering Modifications S/N_____________________________ a. O Column Extension b. O Horizontal Steering c. O Foot Steering
2. Steering Devices a. O Amputee Rings b. O Spinner Knobs c. O Tri-Pin Spinner Knob d. O U-Grip e. O V-Grip f. O Palm Grip
3.
Sensitized Steering and Braking a. O Quad Hand Controls b. O Low Effort c. O Zero Effort d. O Servo Controls e. O Joystick f. O Other (specify)
4. Parking Brake Extensions S/N_____________________________ a. O Manual Parking b. O Electric Parking
5. Switches for Lifts and Door Openers a. O Magnetic Switches b. O Toggle Switches c. O Dash Switches d. O Hand Remote Controls e. O Hand Held Pendent Switches f. O Outside Toggle Switches
6. Hand
Controls a. O Push / Pull b. O Push Right-Angle Pull c. O Push Twist d. O Quad Hand Controls e. O Other (specify) |
7. Other Driving Aids a. O Adapted Key Holder b. O Transfer Handles c. O Transfer Bars d. O Pedal Extensions e. O Cross Over Gear f. O Turn Signals g. O Left Foot Accelerator
8. Vehicle Lifts S/N_____________________________ a. O Hydraulic b. O Electric / Mechanical c. O Platform d. O Under the Floor e. O Automatic f. O Semi-Automatic g. O Rotary (swing)
9. Wheelchair Restraints (tie-downs) a. O Manual b. O Electric
10. Lowered Floors a. O Cargo Lowered b. O Drivers Lowered c. O Wheel Wells d. O Power Pans e. O Gas Tank Modification f. O Body Raise _______ inches
11. Door Openers S/N_____________________________ a. O Power Door Slide b. O Power Side Door Swing c. O Power Rear Door Swing
12. Mini Van S/N_____________________________ a. O 8 inch lowered b. O 10 inch lowered |
13. Secondary Control Switches S/N_____________________________ a. O Toggle Switch b. O Touch Pads c. O Headrest Switch d. O Elbow Switch e. O Other
14. Scooter Lifts and Carriers S/N_____________________________ a. O Pick-up Truck Lift b. O Outside Lift c. O Trunk Lift d. O In-Vehicle Lift
15. Miscellaneous Equipment S/N_____________________________ a. O Removable Driver Seat Base b. O Dual Battery System c. O Power Seat Base d. O After-Market Cruise Control
16. Sub-flooring (plywood / steel) a. O 3/8 inch CDX b. O 3/8 inch Marine c. O 18 gauge Steel d. O None
17. Wheelchair Carriers S/N_____________________________ a. O Car Top b. O Hitch Mount c. O Pick-Up Truck d. O Bumper Mount
18. Raised Tops a. O Reinforced Cage b. O Raised Top c. O Raised Door |
This form must be completed at the end of each month and returned to RADCO. All NMEDA labels used during the month and those on hand must be reported and accounted for. Please mail this form to: RADCO, 3220 E. 59th Street, Long Beach, CA 90805. Columbus Mobility Specialists, Inc. may provide customer information only where allowed by law. RADCO shall only use customer information to support statistical reporting. RADCO shall hold all customer information as confidential and shall not transmit any customer information to NMEDA or any other party.
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Page Revision Date |
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NMEDA QAP |