05 - SAP_SSJ_Form_Master_14JUL2021.pdf

JUSTIFICATION FOR

(Simplified Acquisitions <$250K)

The service or material listed herein is sole source and competition is precluded for reasons indicated below. There are no substitutes available for this material or service.

Restricted to the following source. Provide manufacturer/vendor name. (If sole source manufacturer distributes via dealers, also provide dealer information.)

1. MANUFACTURER 8. DEALER REPRESENTATIVE

2. POINT OF CONTACT 3. PHONE NUMBER 9. POINT OF CONTACT 10. PHONE NUMBER

4. STREET 11. STREET

5. CITY 6. STATE 7. ZIP CODE 12. CITY 13. STATE 14. ZIP CODE

15. ESTIMATED COST 16. REQUIRED DELIVERY DATE 17. STATUTORY AUTHORITY CITED OR OTHER REFERENCE

18. REQUIRED - DESCRIPTION OF THE ITEM OF SERVICE REQUIRES

19. REQUIRED - SPECIFIC CHARACTERISTICS OF THE MATERIAL OR SERVICE THAT LIMIT THE AVAILABILITY TO A SOLE SOURCE [UNIQUE FEATURES, FUNCTION OF THE ITEM, ETC.]. DESCRIBE IN DETAIL WHY ONLY THIS SUGGESTED SOURCE CAN FURNISH THE

REQUIREMENTS TO THE EXCLUSION OF OTHER SOURCES

20. IF APPLICABLE – THE REQUESTED MATERIAL OR SERVICE REPRESENTS THE MINIMUM REQUIREMENTS OF THE GOVERNMENT.

[IF CHECKED, ENTER EXPLANATION OR MINIMUM REQUIREMENTS BELOW]

21. These are direct replacement parts or components for existing equipment (Check if applicable)

NHRC 2019 FRONT

Document Number:

JUSTIFICATION FOR

(Simplified Acquisitions <$250K)

22. IF APPLICABLE – THE MATERIAL OR SERVICE MUST BE COMPATIBLE IN ALL ASPECTS (FORM, FIT, FUNCTION) WITH EXISTING SYSTEMS PRESENTLY INSTALLED/PERFORMING. DESCRIBE THE EQUIPMENT/FUNCTION YOU HAVE NOW AN HOW THE NEW ITEM OR

SERVICE MUST COORDINATE, CONNECT, OR INTERFACE WITH THE EXISTING SYSTEM

23. IF APPLICABLE – A PATENT, COPYRIGHT, OR PROPRIETARY DATA LIMITS COMPETITION. THE PATENT, COPYRIGHT, OR

PROPRIETARY DATA IS:

24. OPTIONAL - OTHER INFORMATION TO SUPPORT A SOLE SOURCE BUY:

I CERTIFY THAT STATEMENTS CHECKED, AND INFORMATION PROVIDED ABOVE, ARE COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THE PROCESSING OF THIS SOLE

SOURCE JUSTIFICATION PRECLUDES THE USE OF FULL AND OPEN COMPETITION.

Signature: Title:

Activity: Date:

Contracting Officer Signature: ______________________________________

Date: ____________________________

SAP Sole Source

NHRC 2019 BACK

Document Number:

BMET Pack PRO-M Ultra-Portable BMET Pack Professional with MOBILIZE Includes:

(1) ST-1-M Safe-T Sim Safety Analyzer with Mobilize

(1) SC-5-M SimCube NIBP Simulator with Mobilize

(1) OX-2-M OxSim Flex SpO2 simulator with Mobilize

(1) SL-8 SimSlim Multi-Parameter simulator

(1) FT-2-M FlowTrax multi-function IV Pump Analyzer with Mobilize All standard accessories for each product included in the NEW BMET Pack Carry Case

Brother P-Touch Cube Plus Bluetooth Printer with extra tape cartridges and soft carrying case.

Apple iPad Air (5th Generation): with M1 chip, 10.9-inch Liquid Retina Display, 64GB, Wi-Fi 6, 12MP front/12MP Back Camera, Touch ID, All-Day Battery Life – Blue