Exhibit L. Unit Price List. Huntingdon County.pdf

EXHIBIT L

RLP NO. 36C24423R0004

LEASE NO. 36C24423L0004

DEPARTMENT/FUNCTIONAL AREA

ROOM

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

PATIENT ALIGNED CARE TEAM (PACT) MODULE EXPA1 3

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1012 TELEPHONE, WALL MOUNTED, 1 LINE 1

C/C A1066 MIRROR, FLOAT GLASS, WITH SS FRAME AR

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C A5145 COAT HOOK, SS, SURFACE MOUNTED 2

C/C A5165 SHELF T-45, SS, 12"WX 5"D 1

C/C A5180

TRACK, CUBICLE CURTAIN, SURFACE MOUNTED,

W/CURTAIN

C/C CD040

CABINET, W/H, 2 SHELF, 2 DO, SLOPING TOP,

38X36X13

C/C CS010 SINK, SS, SINGLE COMPARTMENT, 7.5X12X12 ID 1

C/C CT030 COUNTERTOP, HIGH PRESSURE LAMINATE 1

V/V E0948

CART, GENERAL STORAGE, MOBILE, 42"H X 32"W

X 22"D

V/V F0205 CHAIR, SIDE WITH ARMS 1

V/V F0340 STOOL, SELF ADJUSTING 1

V/V F2010 BASKET, WASTEPAPER, STEP-ON 1

C/C F2310 RACK, PAMPHLET, WALL MOUNTED 1

C/C F3025 BOARD, BULLETIN, WOOD FRAMED 1

C/C F3050 WHITEBOARD, DRY ERASE 1

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

UNIT PRICE LIST

V.A. COMMUNITY BASED OUTPATIENT CLINIC

Lease Title: Huntingdon CBOC

RLP 36C24423R0004

VHA OUTPATIENT CLINIC SPACE PLANNING CRITERIA

EXAM ROOM

Legend: C=Contractor, V=VA Contractor to Complete

INITIALS: ______ Lessor ________ Government Page 1

DEPARTMENT/FUNCTIONAL AREA

ROOM

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/V M0508

CART, TELEMEDICINE, W/ 2 MONITORS, CAMERA,

SPEAKERS, MICROPHONE, AND COMPUTER

C/C M1620

HOLDER, CHART, PATIENT, WALL OR DOOR

MOUNTED

V/V M1801 COMPUTER, W/FLAT PANEL MONITOR 1

C/C M1802

WORK STATION, COMPUTER, RETRACTABLE,

WALL MOUNTED

V/V M3072 FRAME, INFECTIOUS WASTE BAG W/ LID 1

V/V M4100

SPHYGMOMANOMETER, ANEROID, WALL

MOUNTED

V/V M4116 MONITOR, VITAL SIGNS 1

V/V M4200 OTOSCOPE/OPHTHALMOSCOPE, WALL MOUNTED 1

C/C M7401

LIGHT, EXAM, MOBILE, SPOTLIGHT, MOBILE

STAND

V/V M7905 OXIMETER, PULSE 1

V/V M8810 STAND, MAYO 1

V/V M9025 TABLE, EXAMINATION/TREATMENT, W/CABINET 1

C/C RECEPTACLES, DUPLEX 8

C/C LIFT, PATIENT, 625LB, MOBILE, 1-ROOM ONLY 1

V/C SANITIZER, HAND 1

SUBTOTAL 0

CONSULT OFDC2 3

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1012 TELEPHONE, WALL MOUNTED, 1 LINE 1

C/C A1066 MIRROR, FLOAT GLASS, WITH SS FRAME AR

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C A5145 COAT HOOK, SS, SURFACE MOUNTED 2

C/C A5165 SHELF T-45, SS, 12"WX 5"D 1

C/C CD040

CABINET, W/H, 2 SHELF, 2 DO, SLOPING TOP,

38X36X13

C/C CS010 SINK, SS, SINGLE COMPARTMENT, 7.5X12X12 ID 1

C/C CT030 COUNTERTOP, HIGH PRESSURE LAMINATE 1

MH-CONSULT/CONSULT ROOM

INITIALS: ______ Lessor ________ Government Page 2

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/V F0205 CHAIR, SIDE WITH ARMS 1

V/V F0340 STOOL, SELF ADJUSTING 1

V/V F0740 TABLE, OCCASIONAL, LAMP 1

V/V F2000 BASKET, WASTEPAPER, ROUND, METAL 1

C/C F3025 BOARD, BULLETIN, WOOD FRAMED 1

C/C F3050 WHITEBOARD, DRY ERASE 1

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

V/V M1801 COMPUTER, W/FLAT PANEL MONITOR 1

C/C M1802

WORK STATION, COMPUTER, RETRACTABLE,

WALL MOUNTED

C/C RECEPTACLES, DUPLEX 8

V/C SANITIZER, HAND 1

SUBTOTAL 0

PACT PTOT1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1012 TELEPHONE, WALL MOUNTED, 1 LINE 1

C/C A1066 MIRROR, FLOAT GLASS, WITH SS FRAME AR

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C A5145 COAT HOOK, SS, SURFACE MOUNTED 2

C/C A5165 SHELF T-45, SS, 12"WX 5"D 1

C/C CD040

CABINET, W/H, 2 SHELF, 2 DO, SLOPING TOP,

38X36X13

C/C CS010 SINK, SS, SINGLE COMPARTMENT, 7.5X12X12 ID 1

C/C CT030 COUNTERTOP, HIGH PRESSURE LAMINATE 2

V/V E0948

CART, GENERAL STORAGE, MOBILE, 42"H X 32"W

X 22"D

V/V F0205 CHAIR, SIDE WITH ARMS 4

V/V F0340 STOOL, SELF ADJUSTING 2

V/V F2010 BASKET, WASTEPAPER, STEP-ON 2

C/C F2310 RACK, PAMPHLET, WALL MOUNTED 1

C/C F3025 BOARD, BULLETIN, WOOD FRAMED 1

C/C F3050 WHITEBOARD, DRY ERASE 1

PT/OT EXERCISE ROOM

INITIALS: ______ Lessor ________ Government Page 3

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

V/V M1801 COMPUTER, W/FLAT PANEL MONITOR 2

C/C M1802

WORK STATION, COMPUTER, RETRACTABLE,

WALL MOUNTED

V/V M3072 FRAME, INFECTIOUS WASTE BAG W/ LID 1

V/V M4100

SPHYGMOMANOMETER, ANEROID, WALL

MOUNTED

V/V M4116 MONITOR, VITAL SIGNS 1

V/V M4200 OTOSCOPE/OPHTHALMOSCOPE, WALL MOUNTED 1

V/V M7905 OXIMETER, PULSE 1

C/C RECEPTACLES, DUPLEX 12

V/C SANITIZER, HAND 1

SUBTOTAL 0

SUPPORT PEHW1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V M4040 SCALE, WEIGHING, 300LB CAPACITY 1

C/C RECEPTACLES, DUPLEX 6

SUBTOTAL 0

HEALTH CARE ADMINISTRATION (HAS) RECP1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1015 TELEPHONE, DESK, MULTIPLE LINE 6

C/C A6105 COUNTER, RECEPTION CONTROL, BUILT-IN 1

C/C C0038 RAIL, APRON, 4X42X1 5

C/C C0039 RAIL, APRON, 4X48X1 5

C/C C0045 FRAME, APRON, 2 DRAWER, 4X36X22 5

C/C C06M0

CABINET, UNDER COUNTER, PULL-OUT BOARD, 2

DRAWER, 3 FILE DRAWER, 30X18X22

C/C COO46 FRAME, APRON, 2 DRAWER, 4X48X22 5

C/C CT030

COUNTERTOP, HIGH PRESURE LAMINATE,

W/GROUMET HOLES, W/30" EXTENSION

V/V F0275 CHAIR, SWIVEL, HIGH BACK 6

V/V F0405 CABINET, FILING, FULL HEIGHT, 4-5 DRAWER 2

V/V F0420 CABINET, FINLING, LATERAL, HALF HEIGHT 6

V/V F2000 BASKET, WASTEPAPER, ROUND METAL 6

V/V F2540 SHREDDER, PAPER SECURITY 1

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

HEIGHT/WEIGHT STATION

RECEPTION

INITIALS: ______ Lessor ________ Government Page 4

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/V M1801 COMPUTER, W/FLAT PANEL MONITOR 6

V/V M1840 PRINTER/COPIER/FAX COBMINATION 1

C/C RECEPTACLES, DUPLEX 16

V/C SANITIZER, HAND 2

SUBTOTAL 0

PACT WKTM1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1015 TELEPHONE, DESK, MULTIPLE LINE 12

V/V F0275 CHAIR, SWIVEL, HIGH BACK 12

V/V F0415 CABINET, FILING, FULL HEIGHT, 5 DRAWER 12

V/V F0465 CABINET, STORAGE, 2 DOOR, 5 SHELF 6

V/V F2000 BASKET, WASTEPAPER, ROUND METAL 6

V/V F2540 SHREDDER, PAPER SECURITY 1

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

V/V M1801 COMPUTER, W/FLAT PANEL MONITOR 12

V/V M1840 PRINTER/COPIER/FAX COBMINATION 1

C/C RECEPTACLES, DUPLEX 24

V/C SANITIZER, HAND 2

SUBTOTAL 0

WOMEN'S HEALTH/GYN EXW01 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1012 TELEPHONE, WALL MOUNTED, 1 LINE 1

C/C A1066 MIRROR, FLOAT GLASS, WITH SS FRAME AR

C/C A1132

RAIL, ACCESSORY MOUNTING, LENGTH AS

REQUIRED

AR

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C A5145

HOOK, GARMENT, DOUBLE, SS, SURFACE

MOUNTED

C/C A5180

TRACK, CUBICLE, SURFACE MOUNTED, WITH

CURTAIN

AR

C/C CD040

CABINET, W/H, 2 SHELF, 2 DO, SLOPING TOP,

38X36X13

WOMEN'S HEALTH - EXAM ROOM

PACT WORK AREA

INITIALS: ______ Lessor ________ Government Page 5

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

C/C CS010 SINK, SS, SINGLE COMPARTMENT, 7.5X12X12 ID 1

C/C CT030 COUNTERTOP, HIGH PRESSURE LAMINATE 1

V/V E0948

CART, GENERAL STORAGE, MOBILE, 42"H X 32"W

X 22"D

V/V F0205 CHAIR, SIDE WITH ARMS 1

V/V F0340 STOOL, SELF ADJUSTING 1

V/V F2010 BASKET, WASTEPAPER, STEP-ON 1

C/C F2310 RACK, PAMPHLET, WALL MOUNTED 1

C/C F3025 BOARD, BULLETIN, WOOD FRAMED 1

C/C F3050 WHITEBOARD, DRY ERASE 1

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

C/C M1620

HOLDER, CHART, PATIENT, WALL OR DOOR

MOUNTED

V/V M1801 COMPUTER, W/FLAT PANEL MONITOR 1

C/C M1802

WORK STATION, COMPUTER, RETRACTABLE,

WALL MOUNTED

V/V M3072 FRAME, INFECTIOUS WASTE BAG W/ LID 1

V/V M4100

SPHYGMOMANOMETER, ANEROID, WALL

MOUNTED

V/V M4116 MONITOR, VITAL SIGNS 1

V/V M4200 OTOSCOPE/OPHTHALMOSCOPE, WALL MOUNTED 1

V/V M7401

LIGHT, EXAM, MOBILE, SPOTLIGHT, MOBILE

STAND

V/V M7905 OXIMETER, PULSE 1

V/V M8810 STAND, MAYO 1

V/V M9025 TABLE, EXAMINATION/TREATMENT, W/CABINET 1

C/C RECEPTACLES, DUPLEX 8

V/V

LIFT, PATIENT 625LB FLOOR MOUNTED, 1-ROOM

ONLY

V/C SANITIZER, HAND 1

SUBTOTAL 0

WOMEN'S HEALTH/GYN TLTU1 1

C/C A1066 MIRROR, FLOAT GLASS, WITH SS FRAME 1

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

C/C A5090

DISPOSAL, SANITARY NAPKIN, SS, SURFACE

MOUNTED

WOMEN'S HEALTH - EXAM ROOM TOILET

INITIALS: ______ Lessor ________ Government Page 6

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

C/C A5109 GRAB BARS,SS, 1 1/4" DIA. AR

C/C A5145 COAT HOOK, SS, SURFACE MOUNTED 2

C/C A5165 SHELF T-45, SS, 12"WX5"D 1

C/C A5200

DISPENSER, TOILET PAPER W/UTILITY SHELF, SS,

2-ROLL

V/V F2000 BASKET, WASTEPAPER, ROUND METAL 1

C/C P3100 LAVATORY, VITREOUS CHINA, SLAB TYPE 1

C/C P9050 TOILET, WALL HUNG, SIPHON JET 1

C/C

NURSE CALL PULL CHORD, STATION, 2-WALL

MOUNTED LIGHTS

SUBTOTAL 0

EXAM/TREATMENT MODULES (ETM) TRPR1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1011 TELEPHONE, DESK, 1 LINE 1

C/C A1132

RAIL, ACCESSORY MOUNTING, LENGTH AS

REQUIRED

AR

C/C A1165 TRACK, IV, CEILING MOUNTED, 7 FOOT AR

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C A5145

HOOK, GARMENT, DOUBLE, SS, SURFACE

MOUNTED

C/C A5180

TRACK, CUBICLE, SURFACE MOUNTED, WITH

CURTAIN

AR

C/C CD040

CABINET, W/H, 2 SHELF, 2 DO, SLOPING TOP,

38X36X13

C/C CS010 SINK, SS, SINGLE COMPARTMENT, 7.5X12X12 ID 1

C/C CT030 COUNTERTOP, HIGH PRESSURE LAMINATE 1

C/C E0915

LOCKER, SUPPLY, MEDICATION, WALL MTD, 23"W

X 20"D

V/V E0948

CART, GENERAL STORAGE, MOBILE, 42"H X 32"W

X 22"D

V/V F0205 CHAIR, SIDE WITH ARMS 2

V/V F0340 STOOL, SELF ADJUSTING 1

V/V F2000 BASKET, WASTEPAPER, ROUND, METAL 1

C/C F3025 BOARD, BULLETIN, WOOD FRAMED 1

PROCEDURE ROOM

INITIALS: ______ Lessor ________ Government Page 7

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

C/C F3050 WHITEBOARD, DRY ERASE 1

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

C/C M1620

HOLDER, CHART, PATIENT, WALL OR DOOR

MOUNTED

V/V M0750 FLOWMETER, AIR, CONNECT W/ 50PSI SUPPLY 1

V/V M0755 FLOWMETER, OXYGEN, LOW FLOW 1

V/V M0765 REGULATOR, VACUUM 1

V/V M1801

COMPUTER, MICROPROCESSING, W/FLAT PANEL

MONITOR

C/C M1802

WORK STATION, COMPUTER, RETRACTABLE,

WALL MOUNTED

V/V M3070 HAMPER, LINEN, MOBILE, W/ LID 1

V/V M3072 FRAME, INFECTIOUS WASTE BAG W/ LID 1

V/V M4100

SPHYGMOMANOMETER, ANEROID, WALL

MOUNTED

V/V M4116 MONITOR, VITAL SIGNS 1

V/V M4200 OTOSCOPE/OPHTHALMOSCOPE, WALL MOUNTED 1

V/V M4255 STAND, IV, ADJUSTABLE 1

V/V M4655 STRETCHER, MOBILE, CRS, 9 POSITION 1

C/C M5165 SHELF T-45, SS, 12"WX5"D 1

V/V M7401

LIGHT, EXAM, MOBILE, SPOTLIGHT, MOBILE

STAND

C/C M7405 LIGHT, EXAM, CEILING MOUNTED 1

V/V M7710 ELECTROCARDIOGRAPH, 12 LEAD, PORTABLE 1

V/V M7905 OXIMETER, PULSE 1

V/V M8810 STAND, MAYO 1

C/C RECEPTACLES, DUPLEX 8

V/C SANITIZER, HAND 1

SUBTOTAL 0

EYE CLINIC EYOT2 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1012 TELEPHONE, WALL MOUNTED, 1 LINE 1

C/C A1066 MIRROR, FLOAT GLASS, WITH SS FRAME AR

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

TREATMENT ROOM, EYE CARE PROVIDER

INITIALS: ______ Lessor ________ Government Page 8

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C A5145 COAT HOOK, SS, SURFACE MOUNTED 2

C/C A5165 SHELF T-45, SS, 12"WX 5"D 1

C/C CD040

CABINET, W/H, 2 SHELF, 2 DO, SLOPING TOP,

38X36X13

C/C CS010 SINK, SS, SINGLE COMPARTMENT, 7.5X12X12 ID 1

C/C CT030 COUNTERTOP, HIGH PRESSURE LAMINATE 1

V/V E0948

CART, GENERAL STORAGE, MOBILE, 42"H X 32"W

X 22"D

V/V F0205 CHAIR, SIDE WITH ARMS 1

V/V F0340 STOOL, SELF ADJUSTING 1

V/V F2010 BASKET, WASTEPAPER, STEP-ON 1

C/C F2310 RACK, PAMPHLET, WALL MOUNTED 1

C/C F3025 BOARD, BULLETIN, WOOD FRAMED 1

C/C F3050 WHITEBOARD, DRY ERASE 1

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

C/C M1620

HOLDER, CHART, PATIENT, WALL OR DOOR

MOUNTED

V/V M1801 COMPUTER, W/FLAT PANEL MONITOR 1

C/C M1802

WORK STATION, COMPUTER, RETRACTABLE,

WALL MOUNTED

V/V M3072 FRAME, INFECTIOUS WASTE BAG W/ LID 1

V/V M4100

SPHYGMOMANOMETER, ANEROID, WALL

MOUNTED

V/V M4116 MONITOR, VITAL SIGNS 1

V/V M4200 OTOSCOPE/OPHTHALMOSCOPE, WALL MOUNTED 1

V/V M5016 DESK, REFRACTION W/CONSOLE, W/O SINK 1

V/V M5520 LENSOMETER 1

V/V M5530 LAMP, SLIT, W/APPLANATION TONOMETER 1

V/V M5535 OPHTHALMOSCOPE, BINOCULAR, INDIRECT 1

V/V M5545 OPHTHALMOMETER/KERATOMETER 1

V/V M5600 UNIT, EXAM, EYE, W/MOTOR CHAIR, PHOROPTER 1

V/V M5700 FRAME SET, LENS, TRIAL 1

V/V M7401

LIGHT, EXAM, MOBILE, SPOTLIGHT, MOBILE

STAND

V/V M7905 OXIMETER, PULSE 1

V/V M8810 STAND, MAYO 1

INITIALS: ______ Lessor ________ Government Page 9

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/V M9025 TABLE, EXAMINATION/TREATMENT, W/CABINET 1

C/C RECEPTACLES, DUPLEX 8

V/C SANITIZER, HAND 1

SUBTOTAL 0

DAY TREATMENT CENTER OFDC1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1012 TELEPHONE, WALL MOUNTED, 1 LINE 1

C/C A1066 MIRROR, FLOAT GLASS, WITH SS FRAME AR

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C A5145 COAT HOOK, SS, SURFACE MOUNTED 2

C/C A5165 SHELF T-45, SS, 12"WX 5"D 1

C/C A5180

TRACK, CUBICLE CURTAIN, SURFACE MOUNTED,

W/CURTAIN

C/C CD040

CABINET, W/H, 2 SHELF, 2 DO, SLOPING TOP,

38X36X13

C/C CS010 SINK, SS, SINGLE COMPARTMENT, 7.5X12X12 ID 1

C/C CT030 COUNTERTOP, HIGH PRESSURE LAMINATE 1

V/V E0948

CART, GENERAL STORAGE, MOBILE, 42"H X 32"W

X 22"D

V/V F0205 CHAIR, SIDE WITH ARMS 1

V/V F0340 STOOL, SELF ADJUSTING 1

V/V F2010 BASKET, WASTEPAPER, STEP-ON 1

C/C F2310 RACK, PAMPHLET, WALL MOUNTED 1

C/C F3025 BOARD, BULLETIN, WOOD FRAMED 1

C/C F3050 WHITEBOARD, DRY ERASE 1

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

C/C M1620

HOLDER, CHART, PATIENT, WALL OR DOOR

MOUNTED

V/V M1801 COMPUTER, W/FLAT PANEL MONITOR 1

C/C M1802

WORK STATION, COMPUTER, RETRACTABLE,

WALL MOUNTED

V/V M3072 FRAME, INFECTIOUS WASTE BAG W/ LID 1

TREATMENT ROOM, PODIATRY

INITIALS: ______ Lessor ________ Government Page 10

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/V M4100

SPHYGMOMANOMETER, ANEROID, WALL

MOUNTED

V/V M4116 MONITOR, VITAL SIGNS 1

V/V M4200 OTOSCOPE/OPHTHALMOSCOPE, WALL MOUNTED 1

V/V M7401

LIGHT, EXAM, MOBILE, SPOTLIGHT, MOBILE

STAND

V/V M7905 OXIMETER, PULSE 1

V/V M8810 STAND, MAYO 1

V/V M9025 TABLE, EXAMINATION/TREATMENT, W/CABINET 1

C/C RECEPTACLES, DUPLEX 8

V/C SANITIZER, HAND 1

SUBTOTAL 0

LABORATORIES LBVP1 2

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C A5145 COAT HOOK, SS, SURFACE MOUNTED 1

V/V E0948

CART, GENERAL STORAGE, MOBILE, 42"H X 32"W

X 22"D

V/V F2000 BASKET, WASTEPAPER, ROUND, METAL 1

C/C F3025 BOARD, BULLETIN, WOOD FRAMED 1

C/C F3050 WHITEBOARD, DRY ERASE 1

V/V M1410

CHAIR, LABORATORY, BLOOD DRAWING, W/

STORAGE

V/V M1801 COMPUTER, W/FLAT PANEL MONITOR 1

C/C M1802

WORK STATION, COMPUTER, RETRACTABLE,

WALL MOUNTED

V/V M3072 FRAME, INFECTIOUS WASTE BAG W/ LID 1

C/C P3100 LAVATORY, VITREOUS CHINA, SLAB TYPE 1

SUBTOTAL 0

LABORATORIES LBGM1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1013 TELEPHONE, WALL MOUNTED, MULTIPLE LINE 1

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

LABORATORY, GENERAL, OUTPATIENT CLINIC

BLOOD SPECIMEN COLLECTION ROOM

INITIALS: ______ Lessor ________ Government Page 11

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C E0512 MODULE, LAB, WORK SURFACE, O/H CAB, 60" W 1

C/C E0533

MODULE, LAB, WORK SURF, O/H CAB, HVY

STORAGE, 48" W

V/V F0230 CHAIR, DRAFTING, ROTARY 2

V/V F2000 BASKET, WASTEPAPER, ROUND, METAL 1

V/V L0990 ANALYZER, URINE, BASIC 1

V/V L1115

ANALYZER, HEMATOLOGY, DIFFERENTIAL,

AUTOMATIC

V/V L1502 CENTRIFUGE, TABLETOP 1

V/V L8520 SHAKER, ROTATING, 12 STANDARD TUBES 1

V/V M1801

COMPUTER, MICROPROCESSING, W/ FLAT PANEL

MONITOR

V/V M1830 PRINTER, LABEL, PHARMACY 1

V/V M1840 PRINTER/COPIER/FAX COMBINATION 1

V/V M3072 FRAME, INFECTIOUS WASTER BAG W/ LID 1

C/C P1965

EYEWASH, EYE/FACE, SINK MOUNTED, HANDS-

FREE

C/C P2450 VALVE, MIXING, THERMOSTATIC 1

C/C P3100 LAVATORY, VITREOUS CHINA, SLAB TYPE 1

V/V R6280 REFRIGERATOR, LAB, SS, 2 DOOR, 6 SHELVES 1

C/C RECEPTACLES, QUAD 8

V/C SANITIZER, HAND 1

SUBTOTAL 0

LABORATORIES TLTU1 1

C/C A1070 MIRROR, SS FRAMED, 24X36 1

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

C/C A5090

DISPOSAL, SANITARY NAPKIN, SS, SURFACE

MOUNTED

C/C A5109 GRAB BARS,SS, 1 1/4" DIA. 1

C/C A5145 COAT HOOK, SS, SURFACE MOUNTED 2

C/C A5165 SHELF T-45, SS, 12"WX5"D 1

TOILET, URINE SPECIMENT COLLECTION

INITIALS: ______ Lessor ________ Government Page 12

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

C/C A5200

DISPENSER, TOILET PAPER W/UTILITY SHELF, SS,

2-ROLL

V/V F2000 BASKET, WASTEPAPER, ROUND METAL 1

C/C L1200 CABINET, SPECIMEN, PASS THRU, CRS 1

C/C P3200

LAVATORY, VITREOUS CHINA, SLAB TYPE,

ELECTRONIC SENSOR OPERATED - TO BE

REMOTE CONTROLLED (ON/OFF) BY LAB TECH

C/C P9050 TOILET, WALL HUNG, SIPHON JET 1

C/C

NURSE CALL PULL CHORD, STATION, 2-WALL

MOUNTED LIGHTS

SUBTOTAL 0

TELE-HEALTH WRTM2 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1012 TELEPHONE, WALL MOUNTED, 1 LINE 1

C/C A1066 MIRROR, FLOAT GLASS, WITH SS FRAME AR

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C A5145 COAT HOOK, SS, SURFACE MOUNTED 2

C/C A5165 SHELF T-45, SS, 12"WX 5"D 1

C/C A5180

TRACK, CUBICLE CURTAIN, SURFACE MOUNTED,

W/CURTAIN

C/C CD040

CABINET, W/H, 2 SHELF, 2 DO, SLOPING TOP,

38X36X13

C/C CS010 SINK, SS, SINGLE COMPARTMENT, 7.5X12X12 ID 1

C/C CT030 COUNTERTOP, HIGH PRESSURE LAMINATE 1

V/V E0948

CART, GENERAL STORAGE, MOBILE, 42"H X 32"W

X 22"D

V/V F0205 CHAIR, SIDE WITH ARMS 1

V/V F0340 STOOL, SELF ADJUSTING 1

V/V F2010 BASKET, WASTEPAPER, STEP-ON 1

C/C F2310 RACK, PAMPHLET, WALL MOUNTED 1

C/C F3025 BOARD, BULLETIN, WOOD FRAMED 1

C/C F3050 WHITEBOARD, DRY ERASE 1

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

TELE-HEALTH EXAM ROOM

INITIALS: ______ Lessor ________ Government Page 13

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/V M0508

CART, TELEMEDICINE, W/ 2 MONITORS, CAMERA,

SPEAKERS, MICROPHONE, AND COMPUTER

C/C M1620

HOLDER, CHART, PATIENT, WALL OR DOOR

MOUNTED

V/V M1801 COMPUTER, W/FLAT PANEL MONITOR 1

C/C M1802

WORK STATION, COMPUTER, RETRACTABLE,

WALL MOUNTED

V/V M3072 FRAME, INFECTIOUS WASTE BAG W/ LID 1

V/V M4100

SPHYGMOMANOMETER, ANEROID, WALL

MOUNTED

V/V M4116 MONITOR, VITAL SIGNS 1

V/V M4200 OTOSCOPE/OPHTHALMOSCOPE, WALL MOUNTED 1

V/V M7401

LIGHT, EXAM, MOBILE, SPOTLIGHT, MOBILE

STAND

V/V M7905 OXIMETER, PULSE 1

V/V M8810 STAND, MAYO 1

V/V M9025 TABLE, EXAMINATION/TREATMENT, W/CABINET 1

C/C RECEPTACLES, DUPLEX 8

V/C SANITIZER, HAND 1

SUBTOTAL 0

TELE-HEALTH WRTM2 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1012 TELEPHONE, WALL MOUNTED, 1 LINE 1

C/C A1066 MIRROR, FLOAT GLASS, WITH SS FRAME AR

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C A5145 COAT HOOK, SS, SURFACE MOUNTED 2

C/C A5165 SHELF T-45, SS, 12"WX 5"D 1

C/C A5180

TRACK, CUBICLE CURTAIN, SURFACE MOUNTED,

W/CURTAIN

C/C CD040

CABINET, W/H, 2 SHELF, 2 DO, SLOPING TOP,

38X36X13

C/C CS010 SINK, SS, SINGLE COMPARTMENT, 7.5X12X12 ID 1

TELE-RETINAL EXAM ROOM

INITIALS: ______ Lessor ________ Government Page 14

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

C/C CT030 COUNTERTOP, HIGH PRESSURE LAMINATE 1

V/V E0948

CART, GENERAL STORAGE, MOBILE, 42"H X 32"W

X 22"D

V/V F0205 CHAIR, SIDE WITH ARMS 1

V/V F0340 STOOL, SELF ADJUSTING 1

V/V F2010 BASKET, WASTEPAPER, STEP-ON 1

C/C F2310 RACK, PAMPHLET, WALL MOUNTED 1

C/C F3025 BOARD, BULLETIN, WOOD FRAMED 1

C/C F3050 WHITEBOARD, DRY ERASE 1

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

V/V M0508

CART, TELEMEDICINE, W/ 2 MONITORS, CAMERA,

SPEAKERS, MICROPHONE, AND COMPUTER

C/C M1620

HOLDER, CHART, PATIENT, WALL OR DOOR

MOUNTED

V/V M1801 COMPUTER, W/FLAT PANEL MONITOR 1

C/C M1802

WORK STATION, COMPUTER, RETRACTABLE,

WALL MOUNTED

V/V M3072 FRAME, INFECTIOUS WASTE BAG W/ LID 1

V/V M4100

SPHYGMOMANOMETER, ANEROID, WALL

MOUNTED

V/V M4116 MONITOR, VITAL SIGNS 1

V/V M4200 OTOSCOPE/OPHTHALMOSCOPE, WALL MOUNTED 1

V/V M6050

RETINAL IMAGING SYSTEM, FLUORSCEIN /

INDOCYANINE

V/V M7401

LIGHT, EXAM, MOBILE, SPOTLIGHT, MOBILE

STAND

V/V M7905 OXIMETER, PULSE 1

V/V M8810 STAND, MAYO 1

V/V M9025 TABLE, EXAMINATION/TREATMENT, W/CABINET 1

C/C RECEPTACLES, DUPLEX 8

V/C SANITIZER, HAND 1

SUBTOTAL 0

OUTPATIENT CARE WRC01 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

C/C A5210

BRACKET, TELEVISION, WALL MOUNTED, W/

ADJUST ARM

C/C A5220 BRACKET, TELEVISION, WALL BACKING 1

LOBBY, WAITING AREA

INITIALS: ______ Lessor ________ Government Page 15

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/V F0305 CHAIR, WAITING ROOM, SINGLE 16

V/V F0740 TABLE, OCCASIONAL, LAMP 6

V/V F2000 BASKET, WASTEPAPER, ROUND, METAL 1

C/C F2300 RACK, MAGAZINE, WALL MOUNTED 1

C/C F2310 RACK, PAMPHLET, WALL MOUNTED 1

V/V F2420 LAMP, TABLE, WITH SHADE 6

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

V/V M0512

TELEVISION, COLOR, SLIM, 60"W TO 65"W, 16:9

ASPECT RATIO, HD 1080P, HDMI CONNECTIONS

C/C RECEPTACLES, DUPLEX 12

C/C TELEVISION CABLE, JACK, AND WIRING AR

V/C SANITIZER, HAND 3

SUBTOTAL 0

OUTPATIENT CARE SRLW1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V M4705 WHEELCHAIR, PATIENT TRANPORT, FOLDING 4

C/C RECEPTACLES, DUPLEX 4

SUBTOTAL 0

CANTEEN SERVICE SL001 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1012 TELEPHONE, WALL MOUNTED, 1 LINE 1

C/C A1080 MIRROR, POSTURE, WALL MOUNTED 1

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5145

HOOK, GARMENT, DOUBLE, SS, SURFACE

MOUNTED

C/C A5210

BRACKET, TELEVISION, WALL MOUNTED,

W/ADJUST ARM

C/C A5220 BRACKET, TELEVISION, WALL BACKING 1

C/C C02C0

CABINET, U/C/B, 1 SHELF, 1 DRAWER, 1 DO,

36X24X22

C/C C02D0 CABINET, U/C/B, 4 DRAWER, 36X24X22 1

C/C C04P0 CABINET, SINK, U/C/B, 2 DOOR, 36X36X22 1

C/C CB020

CABINET, W/H, 2 SHELF, 1 DO, SLOPING TOP,

38X24X13

C/C CS010 SINK, SS, SINGLE COMPARTMENT, 7.5X12X12 ID 1

STAFF LUNCH/BREAK ROOM

STORAGE, WHEELCHAIR AND STRETCHER

INITIALS: ______ Lessor ________ Government Page 16

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

C/C CT030 COUNTERTOP, HIGH PRESSURE LAMINATE 1

V/V F0225 CHAIR, DINING ROOM 12

V/V F0795 TABLE, DINING 1

V/V F2000 BASKET, WASTEPAPER, ROUND, METAL 2

C/C F3025 BOARD, BULLETIN, WOOD FRAMED, 36 X 24 3

C/C F3050 WHITEBOARD, DRY ERASE 2

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

V/V K1552

BREWER, COFFEE, AUTO, ELECT, 3 BURNER,

FRONT/BACK

V/V K4665 OVEN, MICROWAVE, CONSUMER 1

V/V K8250 TOASTER, POP-UP, 4 SLICE, ELECTRIC 1

V/V M0512

TELEVISION, COLOR, SLIM, 60"W TO 65"W, 16:9

ASPECT RATIO, HD 1080P, HDMI CONNECTIONS

V/V R7000 REFRIGERATOR, 14 CUBIC FEET 1

C/C RECEPTACLES, DUPLEX 10

C/C TELEVISION CABLE, JACK, AND WIRING AR

SUBTOTAL 0

EXAM/TREATMENT MODULES (ETM) CRA01 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1011 TELEPHONE, DESK, 1 LINE 1

C/C A5145

HOOK, GARMENT, DOUBLE, SS, SURFACE

MOUNTED

C/C A5210

BRACKET, TELEVISION, WALL MOUNTED,

W/ADJUST ARM

C/C A5220 BRACKET, TELEVISION, WALL BACKING 1

V/V E0945 CART, COMPUTER, MOBILE, 36"H X 32"W X 22"D 1

V/V F0115 BOOKCASE, OPEN, 5 SHELF 2

V/V F0220 CHAIR, CONFERENCE 12

V/V F0300 CHAIR, TASK, SWIVEL, WITH ARMS 1

V/V F0465 CABINET, STORAGE, 2 DOOR, 5 SHELF 1

V/V F0690

WORKSTATION, COMPUTER, ENCLOSED, WITH

LOCK

V/V F0755 TABLE, CONFERENCE, WOOD 1

V/V F0835 STAND, PROJECTION 1

V/V F2000 BASKET, WASTEPAPER, ROUND, METAL 1

V/V F2225 PROJECTOR, OVERHEAD 1

C/C F3055 WHITEBOARD, WITH SLIDING PANELS. 1

CONFERENCE ROOM

INITIALS: ______ Lessor ________ Government Page 17

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

C/C F3230 RACK, HAT / COAT, WALL MOUNTED 2

V/V M0385 PROJECTOR, MULTIMEDIA/DATA 1

C/C M0400

SCREEN, PROJECTION, 144"X144", REMOTE

CONTROL

V/V M0506

TELEVISION, COLOR, SLIM, 32"W TO 40"W, 16:9

ASPECT RATIO, HD 1080P, HDMI CONNECTIONS

V/V M0507 VIDEO TELECONFERENCING SYSTEM 1

V/V M1801

COMPUTER, MICROPROCESSING, W/FLAT PANEL

MONITOR

C/C RECEPTACLES, DUPLEX 8

C/C MULTI MEDIA CABLE, JACK, AND WIRING AR

SUBTOTAL 0

ADMINISTRATION OPMH1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1011 TELEPHONE, DESK, 1 LINE 1

C/C A5145

HOOK, GARMENT, DOUBLE, SS, SURFACE

MOUNTED

C/C A5210

BRACKET, TELEVISION, WALL MOUNTED,

W/ADJUST ARM

C/C A5220 BRACKET, TELEVISION, WALL BACKING 1

V/V E0945 CART, COMPUTER, MOBILE, 36"H X 32"W X 22"D 2

V/V F0295 CHAIR, STACKING 16

V/V F0435 CABINET, STORAGE, MULTIMEDIA 1

V/V F0860 TABLE, MOBILE 4

V/V F2010 BASKET, WASTEPAPERE, STEP-ON 1

V/V F2250

CAMCORDERE, HANDHELD, HD, ZOOM, W/

MICROPHONE

V/V F3060

WHITEBOARD, PROJECTION SCREEN

COMBINATION

V/V M0506

TELEVISION, COLOR, SLIM, 32"W TO 40"W, 16:9

ASPECT RATIO, HD 1080P, HDMI CONNECTIONS

V/V M1801

COMPUTER, MICROPROCESSING, W/FLAT PANEL

MONITOR

C/C RECEPTACLES, DUPLEX 8

C/C MULTI MEDIA CABLE, JACK, AND WIRING AR

SUBTOTAL 0

ADMINISTRATION CLSC4 1

GROUP THERAPY ROOM

SHARED MEDICAL APPOINTMENT ROOM

INITIALS: ______ Lessor ________ Government Page 18

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V A1011 TELEPHONE, DESK, 1 LINE 1

C/C A5145

HOOK, GARMENT, DOUBLE, SS, SURFACE

MOUNTED

C/C A5210

BRACKET, TELEVISION, WALL MOUNTED,

W/ADJUST ARM

C/C A5220 BRACKET, TELEVISION, WALL BACKING 1

V/V E0945 CART, COMPUTER, MOBILE, 36"H X 32"W X 22"D 2

V/V F0295 CHAIR, STACKING 16

V/V F0435 CABINET, STORAGE, MULTIMEDIA 1

V/V F0860 TABLE, MOBILE 4

V/V F2010 BASKET, WASTEPAPERE, STEP-ON 1

V/V F2250

CAMCORDERE, HANDHELD, HD, ZOOM, W/

MICROPHONE

V/V F3060

WHITEBOARD, PROJECTION SCREEN

COMBINATION

V/V M0506

TELEVISION, COLOR, SLIM, 32"W TO 40"W, 16:9

ASPECT RATIO, HD 1080P, HDMI CONNECTIONS

V/V M1801

COMPUTER, MICROPROCESSING, W/FLAT PANEL

MONITOR

C/C RECEPTACLES, DUPLEX 8

C/C MULTI MEDIA CABLE, JACK, AND WIRING AR

SUBTOTAL 0

ADMINISTRATION SRSE1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V F0295 CHAIR, STACKING 10

C/C RECEPTACLES, DUPLEX 4

SUBTOTAL 0

SUPPORT RCA01 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V E0954 CART, EMERGENCY, MOBILE, 66"H X 52"W X 22"D 1

V/V M1100 RESUSCITATOR, BAG-MASK, HAND OPERATED 1

V/V M1110 RESUSCITATOR, BAG-MASK, HAND OP, INFANT 1

V/V M7660

DEFIBRILLATOR/MONITOR/RECORDER,

PORTABLE

ALCOVE, CRASH CART

SHARED MEDICAL APPOINTMENT STORAGE ROOM

INITIALS: ______ Lessor ________ Government Page 19

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/V M7905 OXIMETER, PULSE 1

V/V M8770

ASPIRATOR/PRESSURE UNIT, GENERAL

PURPOSE

C/C RECEPTACLES, QUAD 4

SUBTOTAL 0

PROSTHETICS AND SENSORY AIDS SRCS1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V M2070 SHELVING, STORAGE, 77HX36WX18D AR

C/C RECEPTACLES, DUPLEX 6

SUBTOTAL 0

SUPPORT COMC1 1

C/C A0900 RELAY RACK, ALUMINUM 1

C/C A0901 CABLE MANAGEMENT, HORIZONTAL BASE UNIT 1

C/C A0902 REAR WIRE FRAME 1

C/C A0903 REAR HINGED COVER, FOR LAN RACK 1

C/C A0904 FIBER OPTIC CABINET, 36 PORT, RACK MOUNTED 1

C/C A0905

ADAPTER PANEL WITH COUPLERS, BLUE, 6

PORT, SM/MM

AR

C/C A0906

ADAPTER PANEL WITH COUPLERS, YELLOW, 6

PORT, SM/MM

AR

C/C A0907 PATCH PANEL, COPPER, UTP

C/C A0908

PATCH PANEL, 110 BLOCK/RJ-45, CAT 5E, 48

PORT,568A

AR

C/C A0910

PATCH PANEL, 110 BLOCK/RJ-45, CAT 5E, 96

PORT,568A

AR

V/C A0911

POWER SUPPLY, UNINTERRUPTIBLE, RACK

MOUNTED

V/V A0912

BATTERY PACK, EXTENDED FOR USE WITH UPS

(A0911)

V/V A0913 SWITCH, LOCAL AREA NETWORK (LAN) 1

V/V A0914

MANAGEMENT PROCESSOR MODULE FOR LAN

SWITCH

V/V A0915 POWER SUPPLY, 725 W, FOR LAN SWITCH 1

V/V A0916 SWITCHING MODULE, DESKTOP, FAST ETHERNET 1

V/V A0917

SWITCHING MODULE, MM FIBER, GIGABIT

ETHERNET SERVER

V/V A0918

SWITCHING MODULE, SM, GIGABIT ETHERNET

SERVER

COMMUNICATIONS ROOM

PROSTHETICS STORAGE ROOM

INITIALS: ______ Lessor ________ Government Page 20

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V F3200 CLOCK, BATTERY, 12" DIAMETER 1

C/C RECEPTACLES, QUAD 8

SUBTOTAL 0

SUPPORT UCCL1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

C/C E0903

LOCKER, SUPPLY, W/SHELVES, WALL MTD, 23"W

X 20"D

C/C E0906

LOCKER, SUPPLY, GENERAL, WALL MTD, 23"W X

20"D

C/C E0912 LOCKER, SUPPLY, MED SURG, WALL MTD 2

V/V F2000 BASKET, WASTEPAPER, ROUND, METAL 1

C/C P8710 UTILITY CENTER, PLUMBING CONNECTION 1

C/C RECEPTACLES, DUPLEX 8

SUBTOTAL 0

SUPPORT USCL1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

V/C A5107

DISPENSER, GLOVE, SURGICAL/EXAMINATION,

WALL MNTD

V/C A5108 WASTE DISPOSAL UNIT, SHARPS 1

C/C C02C0

CABINET, U/C/B, 1 SHELF, 1 DRAWER, 1 DO,

36X24X22

C/C C05P0 CABINET, SINK, U/C/B, 2 DOOR, 36X48X22 1

C/C CS200 SINK, SS, SINGLE COMPARTMENT, 12X28X16 ID 1

C/C CT030 COUNTERTOP, HIGH PRESSURE LAMINATE 1

C/C E0912 LOCKER, SUPPLY, MED SURG, WALL MTD 3

V/V F0530 CART, TRASH 1

V/V F2020 CAN, TRASH, 44 GALLON 1

V/V M3070 HAMPER, LINEN, MOBILE, W/LID 1

V/V M3072 FRAME, INFECTIOUS WASTE BAG W/LID 1

C/C P6350 SINK, FLUSHING RIM, CHINA, 18X26X22 1

C/C RECEPTACLES, DUPLEX 8

SUBTOTAL 0

UTILITY ROOM, CLEAN

UTILITY ROOM, SOILED

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CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

SUPPORT XXYYC 2

C/C R2201

FOUNTAIN, WATER, CRS, WALL MOUNTED, 2-

LEVEL, W/ GLASS FILLER ON ADA FOUNTAIN

SUBTOTAL 0

SUPPORT SRGC1 2

V/V M2025 RACK, STORAGE, CYLINDER, GAS 1

V/V M2055

SHELVING, STORAGE, WIRE, CRS,

W/ADJUSTABLE SHELVES

V/V M2115 TRUCK, HAND, 2 WHEEL 1

SUBTOTAL 0

SUPPORT XXXYYC 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

SUBTOTAL 0

ADMINISTRATION TLTU1 6

C/C A1070 MIRROR, SS FRAMED, 24X36 1

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

C/C A5090

DISPOSAL, SANITARY NAPKIN, SS, SURFACE

MOUNTED

C/C A5109 GRAB BARS,SS, 1 1/4" DIA. AR

C/C A5145 COAT HOOK, SS, SURFACE MOUNTED 2

C/C A5165 SHELF T-45, SS, 12"WX5"D 1

C/C A5200

DISPENSER, TOILET PAPER W/UTILITY SHELF, SS,

2-ROLL

V/V F2000 BASKET, WASTEPAPER, ROUND METAL 1

C/C P3100 LAVATORY, VITREOUS CHINA, SLAB TYPE 1

C/C P9050 TOILET, WALL HUNG, SIPHON JET 1

C/C

NURSE CALL PULL CHORD, STATION, 2-WALL

MOUNTED LIGHTS (NOT NEEDED IN STAFF

TOILETS)

SUBTOTAL 0

SUPPORT SRE01 1

C/C

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V

SHELVING, STORAGE, 77HX36WX18D, OPEN

WIRE, PORTABLE, CLOSED BOTTOM SHELF

V/V FLUIDOTHERAPY UNIT, DOUBLE EXTREMITY 1

V/V CONDITIONER, COLD TREATMENT PACK 1

MEDICAL EQUIPMENT STORAGE

TOILET

TELEPHONE, PUBLIC

STORAGE, STAGING, MEDICAL GAS

WATER FOUNTAIN AREA

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CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

V/V RACK, PACK, HOT/COLD, WALL MOUNTED 1

V/V ICE MAKER, CUBES, 250 POUND, 39X29X26 1

V/V FREEZER, UNDERCOUNTER, 5 CUBIC FEET 1

V/V MONITOR, VITAL SIGNS 2

C/C RECEPTACLES, DUPLEX 8

SUBTOTAL 0

SUPPORT JANC1 1

V/C A5075 DISPENSER, SOAP, DISPOSABLE 1

V/C A5080

DISPENSER, PAPER TOWEL, SS, SURFACE

MOUNTED

C/C A5135

SHELF, UTILITY W/ MOP/BROOM HOLDERS, SS,

SURF MNTD

V/V F0500 CART, JANITOR 1

V/V F0505 BUCKET, MOP, WITH WRINGER, 26 QUART 1

V/V F2525 BURNISHER, FLOOR 1

C/C P1950 EYEWASH, PEDESTAL MOUNT 1

C/C P4700 SINK, MOP, MOLDED STONE 1

C/C RECEPTACLES, DUPLEX, GFCI 8

V/C SANITIZER, HAND 1

SUBTOTAL 0

SUPPORT RECP4 2

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V E0945 CART, COMPUTER, MOBILE, 36"H X 32"W X 22"D 1

SUBTOTAL 0

SUPPORT XXZYY 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

C/C K0450 CURTAIN, AIR 2

C/C RECEPTACLES, DUPLEX, GFCI 8

V/C SANITIZER, HAND 1

SUBTOTAL 0

SUPPORT SRE01 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V M2070 SHELVING, STORAGE, 77H X 36W X 18D 10

C/C RECEPTACLES, DUPLEX, GFCI 8

HOUSEKEEPING AIDS CLOSET (HAC)

STORAGE

KIOSK, PATIENT CHECK-IN

VESTIBULE, FRONT ENTRANCE

INITIALS: ______ Lessor ________ Government Page 23

CODE

QTY OF

ROOMS

FUNCTION

ACQUIRED/

INSTALLED

EQUIPMENT

SYMBOL OR

JSN CODE

ITEM DESCRIPTION QTY UNIT COST PER ROOM TOTAL

SUBTOTAL 0

PACT PHOD2 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V M3150

DISTRIBUTION SYSTEM, MEDICATION,

AUTOMATIC

C/C RECEPTACLES, DUPLEX, GFCI 8

SUBTOTAL 0

PACT LACT1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

V/V F0305 CHAIR, WAITING ROOM, SINGLE 2

V/V F0740 TABLE, OCCASIONAL, LAMP 2

V/V K4665 MICROWAVE, CONSUMER DUTY 1

V/V R6200 REFRIGERATOR, UNDER COUNTER, 5 CU. FT. 1

C/C RECEPTACLES, DUPLEX, GFCI 8

SUBTOTAL 0

PACT ELEC1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

C/C RECEPTACLES, DUPLEX 8

SUBTOTAL 0

PACT FIRE1 1

C/C A1010

TELECOMMUNICATION/DATA OUTLET JACKS, 1-

VOICE, 2-DATA, 1-SPARE

C/C RECEPTACLES, DUPLEX 8

SUBTOTAL 0

Total 0

ELECTRICAL ROOM

FIRE/UTILITY ROOM

MED-ROOM

LACTATION ROOM

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