Sole Source-Brand Name Just Form.pdf

JUSTIFICATION FOR OTHER THAN FULL AND OPEN COMPETITION

(SOLE SOURCE & BRAND NAME)

Department:

POC/Tel. No.:

Proposed Vendor:

Audiology 760-719-3453 E3 Audiometrics

1. Description of the supplies and/or services required to meet the end-user's minimum needs: GSI Audiostar Pro and Tympstar Pro to perform necessary testing and evaluation for patient care.

2. Estimated value of the requirement:

3. What Market Research was used in planning/describing the Government requirement (i.e. eCAT, Prime Vendor, GSA Advantage, GSA/VA Schedules, prior awards, contact with vendor)?

Contact with vendor.

4. If applicable, was the prior Performance Work Statement (PWS) or Statement of Work (SOW) reviewed to ensure they adqauately reflect the current minimum need of the Government?

§i]No

5. Describe the vendor/product unique circumstances/qualifications (i.e. proprietary software) that concludes this is the ONLY vendor/product that can truly satisfy the Government's minimum requirement. Only vendor in California that supplies requested product

6. What is the mission/patient impact if a solicitation was posted for competition allowing vendors to offer alternative/similar products for customer review? Would significantly delay procurement process.

7. Other facts supporting the use of other than full and open competition: N/ A

8. Are there other vendors/sources available in the market that are authorized agents, distributors, or resellers of the manufactured product/services?

Yes or§:}

9. Statement of the actions that are being taken to remove or overcome any barriers to competition:

NIA

(Rev 3-1-05)

DEP~~ ~D l?::v!:0((\,\cic ~ Approved

Comments:

(For requirements >$3,000 up to $500,000)

D Disapproved

Signature of Director/Chairman/Department Head

1' ~~u"--<Yl6\J\ck.J ~'O

D Approved

Comments:

(Rev 3-1-05)

CONTRACTING OFFICER APPROVAL

(For requirements >$3,000 up to $500,000)

D Disapproved

Signature

( (29/ '201.,\ D~te

Date