Purchase Requisition Worksheet Viva.pdf

Purchase Request POTS Number : 22-000230 Vendor Confirmation # :

Credit Card Reference # :

NBS Order No : N/A

1. Requester Requester's Name Raouf Kechrid

Date Needed

2. Recommended Sources

Name of First Vendor

Viva Inform

Phone No.

Company Clerk's Name

Date Ordered : Buyer's Name

Christie HALCOMB

3. Ordering Information 4. Totals

Item No

Exp Type

Cat # CAN - Task Catalog No

DESCRIPTION QTY Unit of Issue LIST PRICE DISC. PRICE ESTIMATED

PRICE

1 31030 7030 8338263- 2022.100 see quote Animal Study Proposal (See page 3)

200.00 HOURS $135.00 $135.00 $27,000.00

Total Item : 1 please continue to page 3 Grand Total List Price: $27,000.00 Grand Total : $27,000.00

443-905-1704 /

AO Approved by Kara Moyer Date :10/19/2021 9:39:24 AM

Approve for Raouf Kechrid by Heidi Graninger Date:10/19/2021 9:24:34 AM

Submitted by Heidi Graninger

Instructions:

The Requester completes Sections 1, 2, and 3. The

NBS Order No.

N/A completes the rest of the form.Buyer

Date Submitted:

10/19/2021

CAN O.C Code

Delivery Point Phone No.

Bldg/Room: 5625/2s08 301.435.6533 11/1/2021

N/A8338263/110375 Organization

HN5523

Decal/Cost Adjust. Needed

Requester's Signature Internal Approval Internal Approval(signature) (signature)

(Provide three sources, if possible. Competition is required for open market and non-mandatory FSS orders over $3,000)

Name of Second Vendor

Name of Third Vendor

Phone No.

Company Clerk's Name

Phone No.

Company Clerk's Name

EIN FSS No.

EIN FSS No.

EIN FSS No.

5. Ordering Mechanism

For radioisotope orders only :

Complete Form NIH 88-1, "Request for Purchase and Use of Radioactive Materials."

Clearance no. of approved radioisotope purchaser

BPA/IDC Source No. Competition Required ? Clearances Required ? Clearances Obtained ?

Yes No Yes No Yes No

6. Mandatory Source Availability

Are any of the items available from these sources? If “yes,” and you are not using the mandatory source, explain why in Item 7.

YES NO

NIH Surplus

NIH Required Source (MAPB, Glassware, etc)

NIH/GSA Stock

YES NO

UNICOR

Blind/Severely

Mandatory FSS Schedules

7. Justification for Not Selecting Mandatory Source

YES NO

OPEN-MARKET Supplies

NIH/GSA Self Service

BPA Call (OM)

SF 44

Internal To/Do

NIH Stock Requisition External To/Do

Purchase Card(s)GSA Fedstrip

BPA Call (FSS) Purchase Order(s)

Purchase Cards/Convenience Checks

Cust Code: 15010

ITR Approved By:Angie Healy Date:10/19/2021 9:48:53 AM

Internal Approval (signature)

See section 11 Required Sources list

Page 1 of 3NIH 1861-1 (Rev. 3/08) FRONT See Reverse

Compatibility with existing equipment.

Other

Mandatory FSS vendor is unacceptable because:

NIH stock item is unacceptable because:

NIH Stores out of stock and urgently needed.

Explain :

Explain :

(specify) :

8. Justification for Sole-source or Other than Small Business on Either Open Market or Non-mandatory FSS

Sole-source: Proprietary data/patent, etc. (FAR 6.302-1.)

Other

Small business is unable to deliver within required timeframe.

Sole-source: Urgent and compelling requirement. (FAR 6.302-2.)

Sole-source: Quality of product required for on-going experiments. (FAR 6.302-1.)

Explain :

Explain :

(specify) :

Explain :

Explain :

Unable to locate small business source(s) for item(s). Explain :

9. Competition (For open market and non-mandatory FSS orders over $3,000.)

Vendor 1

List Price Discount Price Phone No.

Comments

Date Called Company Clerk's Name

Vendor 2

List Price Discount Price Phone No.

Comments

Date Called Company Clerk's Name

Vendor 3

List Price Discount Price Phone No.

Comments

Date Called Company Clerk's Name

10. Price Reasonableness (Check all that apply.)

Lowest price quoted.

Comparison with prices on previous buys where price analysis performed.

Other

Previous order no. Date

(specify) :

YES NO

UNICOR, NIH FSS BPA, FSSI, GSA Advantage or GWAC's

YES NO

NIH OM BPA

The Open Market

Ability One Programs

11.Required Sources for Services

Page 2 of 3NIH 1861-1 (Rev. 3/08) BACK See Reverse

Item List

Item No

Exp Type

Cat # CAN - Task Catalog

DESCRIPTION QTY Unit of Issue

LIST PRICE DISC.

PRICE

ESTIMATED

PRICE

1 31030 7030 8338263- 2022.100 see quote Animal Study Proposal and Institute Animal Use Database and monitoring system 200 hours @ $135/hr = $27,000

200.00 HOURS $135.00 $135.00 $27,000.00

Total List Price

$135.00 Total : $27,000.00

PA Notes : NA

Requester Notes :

Justification : Item is needed to help ASP approval and tracking process, creating animal cage cards, animal usage inventory, and generating reports required by policy and regulations for using animals in research at NIH.

Page 3 of 3NIH 1861-1 (Rev. 3/08) BACK