WCBVI-WSD-DOA-3831 Piggyback Request-Airgas 3.30.22.doc
DOC document 702 KB Posted
- Attached to
- Medical Gases and Industrial Gases
- Contract number
- 410014-M22-CJO8129-COP-01
- Issued by
- Wisconsin
About this file
This document is a STAR Piggybacking Request form from the State of Wisconsin Department of Administration, facilitating an interagency contract utilization between the Wisconsin Center for the Blind and Visually Impaired (requesting agency) and the Wisconsin Department of Corrections (originating agency). The request involves Airgas USA LLC (Supplier ID 0000034136) under contract number 410014-M22-CJO8129-COP-01, which was competitively bid through RFB #CJO-8129. The Wisconsin Center for the Blind and Visually Impaired is seeking to piggyback on the Department of Corrections' existing contract arrangement with Airgas.
The contract covers the purchase of medical and industrial gases, rental of gas cylinders, tanks and dewars, as well as rental of rollerbases and other cylinder transport medical equipment. The agreement includes off-site filling services for agency-owned cylinders at the contractor's facility. The contract is effective from January 1, 2022 through December 31, 2022, with two additional two-year renewal options available. The Wisconsin Center for the Blind and Visually Impaired estimates an annual spend of $4,000 under this arrangement. The original contract allows other state agency locations to piggyback if agreeable to Airgas USA LLC, with Ashley Kraft serving as the designated contact at (920) 757-2338.
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Text version
State of Wisconsin
Department of Administration
DOA-3831 (r03/2020)
S. 16.71 Wis. Stats
State Bureau of Procurement
101 East Wilson Street, 6th Floor
P. O. Box 7867
Madison, WI 53707-7867
STAR Piggybacking Request Instructions: Send the completed form via e-mail to:
Section 1: Agency Requesting Piggyback
| Agency Requesting Piggyback: |
| Agency Business Unit Number: |
| Wiscosnin Center for the Blind and Visually Impaired |
| 25500 |
| Agency Contact Name: |
| Phone Number: |
| E-Mail Address: |
| Theresa Eiden |
| 608-758-6156 |
| theresa.eiden@dpi.wi.gov |
FORMCHECKBOX
My agency has notified the Originating/Contracting Agency identified in Section 2 below that we intend to use their contract and they have agreed.
Section 2: Originating/Contracting Agency
| Originating/Contracting Agency: |
| Agency Business Unit Number: |
| Department of Corrections |
| 41000 |
| Originating/Contracting Agency Contact Name: |
| Phone Number: |
| E-Mail Address: |
| Charlene Orsted, Contract Manager |
| 608-240-5583 |
| charlene.orsted@wisconsin.gov |
Section 3: Contract Information
| Contract Number |
| Supplier Name |
| Supplier ID Number |
| 410014-M22-CJO8129-COP-01 |
| Airgas USA LLC |
| 0000034136 |
| Commodity/Service Codes: |
| 43092 |
| Estimated Annual Spend: |
| $4,000.00 |
Is the purchase of software included in this request? If “yes”, complete Section 5 below. Yes FORMCHECKBOX No FORMCHECKBOX
N/A FORMCHECKBOX
Section 4: Eligibility Check
FORMCHECKBOX
My agency has validated the following, in compliance with the requirements of the State Procurement Manual, PRO-502.
FORMCHECKBOX
Contract is Open
| Contract Effective Dates: |
| 01/01/2022 - 12/31/2022 |
| Renewal Options: |
| two, 2-yr renewals |
FORMCHECKBOX
Competitively Bid
| Request for Bid/Proposal Number: |
| RFB #CJO-8129 |
FORMCHECKBOX
Supplier(s) is/are not on the Certification for Collection of Sales and Use Tax Ineligible Vendor Directory
FORMCHECKBOX
Supplier(s) is/are not on the Contract Compliance Ineligible Vendor Directory
Impact, if any, on any minority business enterprise, disabled veteran-owned business or work center:
None
FORMCHECKBOX
Contract scope matches my agency’s need.
Description of the scope of the original procurement and how it corresponds to the commodity/service to be purchased:
The purchase of DOC and DHS medical and industrial gases, and the rental of the gas cylinders, tanks and dewars. Also the rental of Rollerbases and other cylinder tranport medical equirpment. Any Agency owned cylinders are filled off-site at Contractor's facility.
Other Agency locations may piggyback on this Contract if agreeable to Airgas USA, LLC. Contact Ashley Kraft at ashley.kraft@airgas.com (920) 757-2338
State Bureau of Procurement Use Only
Request Approved:
FORMCHECKBOX
Yes FORMCHECKBOX No Date:
Approved By (Initial):
If UW, STAR Contract Number Assigned:
Section 5: Software Purchase Impact on STAR System
State agency software purchases must be compliant with the STAR Software Purchasing Policy (see PIM 17-001 and additional reference material attached therein). Please complete Section 5 for software purchases and include a technical contact that can be reached for questions related to your agency’s request.
Agency Technical Contact Name:
Phone Number:
E-Mail Address:
FORMCHECKBOX
My agency has reviewed the in-scope modules of the STAR System and we do not consider the requested software to overlap or conflict with system functionality.
FORMCHECKBOX
My agency has reviewed the in-scope modules of the STAR System and the requested software does appear to overlap or conflict, in whole or in part, with system functionality. We hereby request that approval be granted to make the purchase.
Provide a rationale for approval of the request where there appears to be a conflict or overlap with the STAR System:
This document can be made available in alternate formats to individuals with disabilities upon request.
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