Emergency Procurement Form

Commonwealth of Pennsylvania

EMERGENCY PROCUREMENT ("EP") APPROVAL REQUEST

If either of the following two conditions exist, an EP is not required and should not be requested: 1. Material/Service available from DGS/OA statewide contract. 2. Estimated Cost of the material/service is within the Small, No-bid Procurement threshold identified in the Procurement Handbook, Part I, Chapter 7. Agency requests approved to proceed with an emergency procurement under Section 516 of the Commonwealth Procurement Code (62 Pa. C.S. § 516).

New Form Edit Form Extensions	Status:

Requesting Agency Information

Agency/Bureau:*

Contact Person:*

Street Address:*

City, State, ZipCode*

City*

State: Pennsylvania

Zip Code*

Contact Tel#:*

Contact Email:*

Confirm Email:*

Description of Material
or Service
or IT:*

Material
Service
IT

For IT-Services and IT-Materials, please choose IT.

Material Group
or Product Category:*

Estimated $ Amount:*

Length of EP:*

Delivery Location:*

City*

State: Pennsylvania

Zip Code*

Choose only one

Basis for the Emergency Purchase

Threat to public health, welfare, or safety

Identify the threat and provide an explanation as to what created threat:

Provide a brief explanation of the need for the material and/or service:

State the consequence if the procurement is not done on emergency basis:

Indicate whether approval was obtained from DGS:

Yes
No

If Yes Provide the following:

a. Name of person granting approval:

b. Date of approval:

Circumstances outside the control of the agency create an urgency of need, which does not permit the delay in using more competitive methods

Note: Verbal approval will not be provided for this basis. Agency cannot proceed with emergency procurement until this form is completed and approved by DGS/OA.

Identify the Circumstances:
Why are those circumstances outside of the control of Agency?
Provide a brief explanation for the urgent need:

Information Required
*For ALL EP's, provide the following information:*

Brief description of selection process

Full Supplier information:
(if known at the time of
submission of form)

Name:
Address:
Telephone#:
SAP Vendor#

For EP's that are NOT a threat to public health, welfare, or safety, provide the following information

Include a list of the solicited suppliers, their contact information, and their quotations:
Funds have already been encumbered for this request(Yes/No):	Yes No
If applicable, what has been done previously to procure this material/service? (Also provide the previous SAP/SRM PO number and/or Contract Number):

NOTE: If any Agency only intends to solicit a quote from one supplier, the following section, "Supplemental Single Source Information" must be completed

Supplemental Single Source Information Required
This section of the EP APPROVAL REQUEST Form is only required to be completed if the following is applicable: 1. Category of Emergency is due to "Circumstances outside the control of the agency create an urgency of need, which does not permit the delay in using more competitive methods." 2. It is not practical for the agency to obtain two or more quotes.

Is only a single supplier capable of providing the material or services? If yes, please explain. If not applicable, leave blank and respond in the next block.
Explain why it is not practical to obtain two or more quotes for this emergency procurement.
If timing is a factor, what is the time factor and why? If yes, please explain.
Are there compatibility requirements or compliance requirements? If yes, please explain

NOTE: If the purpose of the emergency procurement is to prevent a lapse in contracted services, one of the following must be checked. Include status of the new contract/purchase order and note any special conditions of the emergency procurements.
DGS/OA will not accept delay in new contract being executed as a basis for an EP unless the Agency can provide detailed, justifiable explanation for the delay.

To extend a current contract with the current contractor to prevent a lapse in contracted services
To bridge a gap between an expiring contract and a new contract by allowing the new contractor to begin work before the new contract is fully executed.
To authorize a supplier, who has been selected through one of the methods of award, to begin work before the new contract is fully executed because the agency needs the services immediately and cannot wait until full execution of the contract/purchase order
If none of the above is applicable, explain how the emergency supplier was selected

Agency Approvals

IMPORTANT*:The printed names on this form shall constitute the signatures of these individuals. Agencies must insure that these individuals review the completed form and give their consent to apply their printed name on this form. No handwritten signatures shall be required in order for the form to be considered "signed" by those individuals whose names appear in the signature section of the form

Requesting Authority (Agency Head or Designee reviewing and approving this request). Requesting Authority signature connotes concurrence with the Agency EP request to procure the material and/or service

Title:*
Signature:*
Date:*

If you wish to receive a copy of the approval/disapproval/returned for correction e-mails, please provide your e-mail address below


Attachment:

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Approval Process:

	E-mail:	By clicking this button, the form will be submitted to DGS/OIT depending upon the category selected.