PurchaseRequisitionWorksheet.pdf

Purchase Request POTS Number : 22-003249 Vendor Confirmation # :

Credit Card Reference # :

NBS Order No : N/A

1. Requester Requester's Name John Czapary

Date Needed

2. Recommended Sources

Name of First Vendor

MathWorks

Phone No.

Company Clerk's Name

Date Ordered : Buyer's Name

John Burton1/21/2022

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 31031 7A21 8021651- 2022.100 na 1 Campus Wide Suite ( (See page 3)

1.00 EACH $71,630.00 $71,630.00 $71,630.00

Total Item : 1 please continue to page 3 Grand Total List Price: $71,630.00 Grand Total : $71,630.00

508-647-7000 /

AO Approved by Marlene Taulton Date :1/20/2022 8:23:44 AM

Approved by Ryan Dale Date:1/19/2022 10:21:26 PM

Submitted by John Czapary

Instructions:

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

NBS Order No.

N/A completes the rest of the form.Buyer

Date Submitted:

01/14/2022

CAN O.C Code

Delivery Point Phone No.

Bldg/Room: 6710B/3351D 301-326-7991 1/21/2022

310318021651/140458 Organization

HNT415

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: 90536

N/A Date:N/A

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) :

See Sole Source Justification

See Sole Source Justification

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 31031 7A21 8021651- 2022.100 na 1 Campus Wide Suite (CWSSMS). Period of Performance 04/01/2022 to 03/31/2023.

Reference Quote# 12634723.

1.00 EACH $71,630.00 $71,630.00 $71,630.00

Total List Price

$71,630.00 Total : $71,630.00

PA Notes : NA

Requester Notes :

Justification : Institute Wide License (IWL) for all Simulink /Matlab and Toolboxes used by DIR labs in their 'basic and applied research. All products are available to the entire NICHD DIR community and Activation Reports of all users are generated for license tracking/ management.

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