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 University personnel.
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 attached
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 Corporate Controller. 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 this request
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 form
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 known consultant to perform this service in this region, give support of the need for immediate service as the primary requirement for consultant election.
Indicate other specific requirements necessitating single source procurement.
Additional support documentation is attached. Check Yes or No