ESI Juvare - WebEOC Rebimbursements SS.pdf

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Sole Source Request § 24-103-205, C.R.S.

Instructions:

1. Complete all fields below. Failure to provide all information may delay the processing of your request.

2. Include any documentation to support your request as attachments with the form.

3. Submit the complete form, with attachments to tammy.lichvar@state.co.us

SECTION A – Agency Information

1. Division / Office:

2. Name of Requester:

3. Name of Program Manager:

SECTION B – Vendor Information

1. Vendor Name:

2. Vendor Contact:

3. Vendor Phone Number:

4. Vendor Email:

5.

• If yes, please explain:

A sole source procurement is justified when there is only one good or service that can reasonably meet the need and there is only one vendor who can provide the good or service. A requirement for a particular proprietary item (i.e., a brand name specification) does not justify a sole source procurement if there is more than one potential bidder or offeror for that item. Note: All sole source requests will be posted on an electronic procurement system in accordance with §24-106-103(5) C.R.S.

Have you procured goods and/or services from this vendor in the past 2 years?

Choose: Yes No

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SECTION C – Description of Goods/Services

1. Describe in detail the goods and/or services to be procured and how they meet your needs i.e., special features, compatibility, etc.:

2. Are there other goods or services that can meet the state’s needs? Choose

• If yes, please explain:

SECTION D – Approval Period and Estimated Dollar Amount

1. Is this purchase a one-time purchase?

• If no, identify approval period being requested:

Start Date (MM/DD/YY):

End Date (MM/DD/YY):

2. Provide estimated cost breakdown of goods and/or services covered by this procurement:

Goods:

Services:

TOTAL DOLLARS for this procurement:

SECTION E – Price Reasonableness

1.

2.

3. Was a cost or price analysis conducted:

4. If you answered 'YES' to 1-3 above, attach documentation of how you determined Price Reasonableness. If you answered ‘NO’ to 1-3 above, describe how the agency determined the prices were fair and reasonable, as required by §24-103-403 C.R.S. and §24-30- 202 C.R.S. for this sole source:

Yes No

Yes No

NoWere the prices or rates compared to established catalog or market prices? Yes

Were the prices or rates compared to historical prices or rates for similar goods or services procured by in the past? Yes No

Yes No

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SECTION F – Sole Source Justification

1. Provide a detailed explanation of the vendor's Sole Source Status. WHY we MUST buy this particular good and/or service from this Vendor.

2. If this request is NOT approved, what method of source selection would the agency/IHE use to satisfy the requirements of the Procurement Code?

3. Is there any additional information that you’d like to provide in order for this request to be considered?

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By signing below, you are certifying that the information submitted on this form is accurate.

The EDO Purchasing Director will make the final determination of Sole Source.

Signature __________________________________________ Date ___________

Printed Name and Title _________________________________________

FOR PROCUREMENT USE ONLY:

NPSS1 Number Posted on VSS and

Related Comments (responses received, quantity, etc):

DETERMINATION:

Sole Source approved – purchase as requested.

Sole Source not approved – issue bid using performance specifications.

MARKET RESEARCH CONDUCTED BY PROCUREMENT STAFF:

Director of Purchasing (or delegate) Signature ____________________________________

This approval is valid until: _______________