UTMB-Galveston Capital Equipment Medical Equipment Request Questionnaire Page 2

TRACKING NO:

CES Use Only Equipment Request Questionnaire

Department: Date Submitted: Prepared by:

Select one: New Replacement Expansion Upgrade Minor Equipment <$5,000

Requested funding: ______Source Department Account # Hospital Capital Fund Other 1. Equipment Description Name of Equipment: Describe Function:

2. Building/Room where equipment will be located.

3. Please list all available manufacturers beginning with your preferred manufacturer first. Equipment Installation Manufacturer Model Cost (List) Qty Shipping Cost $(Est) Total Cost

(1 – 99) Priority of this requisition in relationship to your other requests this cycle.

Please complete items 4 and 5 if this request is for replacement equipment. Skip to item 6 if this request is for new, expansion, or upgrade equipment. (Attach an asset number listing if more than one item with Asset Number is being replaced)

4. Items to be replaced. Asset Number: Other Identification: Serial Number: Name of Equipment: Manufacturer Name Model Number

5. Reason for replacement. Maintenance costs too high. Yes No Parts no longer available. Yes No Equipment unreliable and past useful life. Yes No Other, explain: Yes No Equipment Request Questionnaire Page 2

6. Site preparation requirements. Identify if Equipment will require: Standard electrical and / or emergency power. Yes No Building modifications to install or use. Yes No Water, sewer/drainage, or steam connections. Yes No Compressed gas, air, oxygen, or vacuum utility connections. Yes No Radiation, laser, radio waves, or radioactive components permits or review Yes No Special structural support due to weight or size Yes No Modifications to heating, ventilation, or air conditioning. Yes No Installation by: Vendor In-house Yes No Additional construction or renovation of current space Yes No If yes please describe:

Comments on any special needs listed above:

7. List external approvals or registrations required for this acquisition: Operating Certificates Yes No Regulatory approvals (specify) Yes No Laser, nuclear or x-ray registrations Yes No Other (explain):

8. Why is the equipment needed? (new technology, replacement, increased volumes etc.)

9. Explain any efficiency gained with this piece of equipment. (e.g. staff will be more efficient, procedure time will decrease, etc.) Equipment Request Questionnaire Page 3

10. Financial Considerations Describe the ANNUAL cost and revenue impacts of the acquisition. Year 0 numbers should reflect the IMMEDIATE cost impacts of the acquisition. Year 1-3 numbers should reflect the ONGOING operational impact of the acquisition for the first three years. “Costs” refer to Incremental INCREASES in expense associated with new piece of equipment. “Cost Savings” refer to Incremental DECREASES in operating expense. “Revenues” refer to Incremental REVENUE INCREASES from the new piece of equipment. Dollars should not be inflated in years 2-3.

Year 0 Year 1 Year 2 Year 3 Costs Additional FTEs (salaries & fringe)* Supplies Maintenance Renovation & Installation Other (please specify) Total Costs Cost Savings Reduced FTEs (salaries & fringe)* Supplies Maintenance Other (please specify) Total Cost Savings Revenues Additional Units of Service Additional Patient Revenues Other Additional Revenues Total Revenues

PLEASE NOTE: Cost Savings identified from reduced FTEs, supplies, maintenance or any other savings will be removed from the requester’s operating budget.

*Please identify the title, salary and number of the proposed additional FTEs or reduced FTEs in the table below. In calculating an annual salary for bi-weekly employees assume one FTE=2080 hours per year. Fringes benefits should be estimated.

Titles Salary & Fringe $’s Number/Qty Equipment Request Questionnaire Page 4

REVIEWS: Department Manager Approval (Required for all requests)

Printed Name:______Telephone #: ______

Signature: ______Date:______

REVIEWS and APPROVALS

Executive Director Approval:

Printed Name: ______Telephone #: ______

Signature: ______Date: ______

(Required for requests >$10,000 on department operating funds and on all requests made on the Hospital Capital accounts.

CEO Approval

Signature : ______Date:______Karen H. Sexton, RN, PhD, CHE Vice President & Chief Executive Officer UTMB Hospitals & Clinics

(Required for all requests >$25,000 on the department funded requests and all requests made on the Hospital Capital accounts) Equipment Request Questionnaire Page 5 Department Reviews: (This section will be completed by the Capital Equipment Committee, do not forward your requests to these support Departments)

Clinical Equipment Services FOAM Information Services Value Analysis Procurement

1. Do you expect support 1. Is site modification required? 1. Will CSN Connections 1. Are supplies needed 1. Will competitive bid problems? be needed? to operate? be sought? Yes No Yes No Yes No Yes No Yes No 2. Maintenance will be provided: 2.Maintenance will be provided: 2. Are interfaces to other 2. Will equipment 2. Are comparable systems needed? duplicate or eliminate technologies In-house Service Contract In-house Other current supplies? available? Yes No Yes No Yes No If question 1 is Yes, explain: If Yes or Other, explain: If question 2 is yes, explain: Explain: Estimate Pricing:

3. Other considerations: i.e., 3. Other considerations 3. Other considerations 3. Other considerations 3. Other considerations Risk Rank, Life Expectancy Improved patient flow.

4. Cost of following (if required): 4. Cost of following (if required): 4. Cost of following (if required): Annual Service Annual Service Annual Service Contract Contract Contract Training N/A Training Training Test/Support N/A Test/Support Test/Support Equip Equip Equip

Bill Willison

Signature: (Director of CES) Signature: (FOAM) Signature: (I.S. Manager) Signature:(Value Analysis) Signature: (Logistics) Date: Date: Date: Date: Date: