Information
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Region:
- Western
- Central
- Southwest
- Midwest
- Northeast
- Southeast
- Florida
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Facility Name:
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Work Order No.
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Conducted on
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Project Title:
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Prepared by
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Name of project lead:
About the Project:
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Reason / Justification (Provide detail justification, implication, and expected results)
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Type of Improvement:
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Will the current asset will be:
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Trade-in value: $
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Estimated start date / purchase date:
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Expenditure is?
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Budget Amount:
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National Institution approval if un-budgeted:<br>
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Budget Amount:
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Year Budgeted:
Quotations:
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Was requirements list shared with potential vendors to obtain quotes? (in alignment with National Institution guidelines)
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Add Vendors
Vendors:
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Date of Quote
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Vendor Name
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Is this a formal/written quote on:
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Does the quote specify work details?
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Are quotes comparable and provide similar type of breakdown?
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Is the quoted amount for the entire purchase including taxes (i.e. no additional costs?"
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Summarize quote Warranty/Guarantee:
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For services, does the vendor have Workman’s Compensation Liability? (Please obtain copy).
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If no, has Vendor signed Liability Release Form?
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Will volunteers be utilized?
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Please describe:
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Additional Considerations/ Risk Factors:
Costs & Funding:
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Total Cost (include materials, labor, taxes, shipping, warranty, etc.):
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Less Trade-‐In:
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Net Cost:
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Variance $ (Net Cost – Budget):
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Variance % (Net Cost – Budget)/Budget:
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Variance Explanation (if over 5%)
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Funding from Imamat:
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Recommended Vendor by Institution:
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Additional Comments:
National Reviews:
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PMP Comments:
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GRB Comments:
Approvals:
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IMARA Sign-off:
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Position:
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Date:
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PMP Sign-off:
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Position:
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Date:
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National GRB Sign-off:
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Position:
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Date:
