Capital Requisition Form

Capital Requisition Form

Requesting Department
Date / Department: / ContactName: / CostCenter: / Phone:
Deliver To: / Fiscal Yr: / Budgeted: / Yes No / Funded by GHCH Foundation: / Yes No
Item No. / QTY / Unit of Measure / Manufacturer & Model / Description / Unit Cost / Extension
Total Cost / $
Suggested Vendor: / CARDINAL HEALTH / Vendor #: / Vendor Contact Name: / Phone:
If assembly/install required, indicate installer: / Vendor
Other – who? / If vendor installed, any cost should be included in quote. / Are service/operations manuals included with purchase? / Yes
No / Is biomedical Eng. training included? / Yes
No
Submission to VAC Committee
(Medical Equip. Only): / Yes No…..requires justification / Bid Process: / Yes No…..requires justification
Required Support Department Review
Biomedical Engineering / IT Department (Computer Related or Support Equipment)
Is equipment electrical? / No Yes / Will Biomedical cover service for this equipment? / No
Yes / Will IT cover service for this equipment? / No
Yes / Comments/Recommendations:
Warranty Terms: / Estimated annual maintenance costs post-warranty: / Is this identical to any existing GHCH equipment? / No
Yes
Engineering Department / VAC Committee
Installation Costs/Comments / Comments:
Purchasing Department / Finance Department
Comments / Is this equipment replacing current equipment? / No Yes…. List Asset Tag #(s) of
disposed items. / G/L Asset Acct. #:
Routing and Signatures
Requested by: / Date: / Biomedical Eng. Approval: / Date: / IT Approval: / Date:
VAC Approval: / Date: / Engineering Approval: / Date: / Supply Chain Operations Approval: / Date:
Quality Director Approval: / Date: / COO Approval: / Date: / CNO Approval: / Date:
Executive Director HR Approval: / Date: / CFO Approval: / Date: / CEO Approval: / Date:
For Purchasing Use Only
Date
Received: / Quote Review Completed: Yes / Date PO Placed: / PO No: / Buyer: / Comments: