Scope of Work - Check box options - Complete page 3 of this document or attach separate sheets.
Need - Indicate why the services to be provided are essential and cannot be provided by
Customary Fee - What is the customary fee for services of this nature? Cite previous cases, if
possible. Include all documentation you may have received. Check box if documentation is
Qualified Consultants - Listing of capable qualified consultants and rates. Place an "X" before
the name of the preferred consultant. If anticipated cost if $10,000 or more, informal
quotations must be attached. Check box if documentation is attached.
Qualified Consultants table - Table consists of four columns, a header row, and five rows for
data. Column 1 reads "Place an X before the name of the preferred consultant. Column 2 - Enter
consultant names. Column 3 - Enter complete address of the consultant. Column 4 - Enter
consultant rate (itemized expenses not included in rate)
Criteria for Selection - Specify the required criteria for selecting a suitable consultant for
the scope of work to be performed.
Funding Source - Is the consultant to be paid utilizing sponsored award funds? Check Yes or No
Funding Source - if Yes - Is sponsor approval required? Check Yes or No. If sponsored approval
is required, a copy of request for approval, and an indication of the status of the request,
must be attached.
If Yes to sponsor approval - indicate the Prime Contract Number
Consultant is to provide services for the period of - Enter beginning date
Consultant is to provide services for the period of - Enter the ending date
Are travel expenses included in the stated rate? - Check Yes or No
If No, University travel policies will govern the rate and rules of reimbursement for travel
expense unless a written exception is obtained from the Associate Vice President for Finance. Such an exception
is permissible ONLY when sponsored awards are NOT involved.) Is a written exception attached?
Check Yes or No
Single/Sole Source Justification - If the anticipated cost for the consultant is $10,000 or
more, and either only one Consultant is listed under Item #4 OR a specific Consultant is
required, then the Single Source Justification form must be completed. Check box if the Single
Source Justification has been completed
Name - Enter the name of the individual responsible for making this request
Title - Enter the title of the individual responsible for making this request
Campus Mailing Address - Enter the campus mailing address of the individual responsible for
making this request
Phone - Enter the telephone number, including the area code, of the individual responsible for
making this request
Fax - Enter the fax number, including the area code, of the individual responsible for making
Email address - Enter the email address of the individual responsible for making this request
Signature - Upon completion, the individual responsible for making this request must sign the
Date - The individual responsible for making this request must date the form as well
Scope of work - Provide full specification of work to be completed
What are the unique qualifications which make this consultant the only qualified consultant for
the services to per performed? Give very specific characteristics or other supporting research
to justify the need for this particular consultant.
If this is the only known consultant to perform this service, what research has been done to
support this claim?
If this is the only
consultant to perform this service
in this region
, give support of the need for immediate service as the primary requirement for consultant
Indicate other specific requirements necessitating single source procurement.
Additional support documentation is attached. Check Yes or No