JUSTIFICATION FOR EQUIPMENT



JUSTIFICATION FOR NEW / REPLACEMENT EQUIPMENT REQUESTCommittee (Check One) FORMCHECKBOX Information Technology FORMCHECKBOX Capital EquipmentType of Equipment (Check One) FORMCHECKBOX Instructional FORMCHECKBOX Non-InstructionalEQUIPMENT REQUESTED FORMTEXT ?????Please include/attach a narrative summary explaining use, purpose and need of this equipment item.. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Estimated Current Cost / Per Item: FORMTEXT ?????Quantity FORMTEXT ?????Total This Request FORMTEXT ?????Equipment Life Span (In Years):Life expectancy: FORMTEXT ?????Technological life: FORMTEXT ?????Meet Educational Needs: FORMTEXT ?????A.Is this Replacement Equipment? (Check One) YES FORMCHECKBOX NO FORMCHECKBOX If ‘YES’ & multiple items complete Page 3 & proceed to BIf no, continue to Part BIf ‘YES’ & single item, complete the followingIHCC Tag # to be Replaced: FORMTEXT ?????Date of Original Purchase: FORMTEXT ?????What is the condition of the equipment this will replace?Safety Issue? YES FORMCHECKBOX NO FORMCHECKBOX FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorDisposal Method Proposed for Item Being Replaced: FORMTEXT ????? FORMTEXT ?????B.Usage:1)Current Fall Enrollment by Applicable Program(s):Program: FORMTEXT ?????# of Students: FORMTEXT ?????Program: FORMTEXT ?????# of Students: FORMTEXT ?????Program: FORMTEXT ?????# of Students: FORMTEXT ?????Term Used: FORMCHECKBOX Fall FORMCHECKBOX Winter FORMCHECKBOX Spring FORMCHECKBOX SummerAverage # of Students/Term FORMTEXT ?????(Check all that apply)Frequency of Use: FORMCHECKBOX Daily FORMCHECKBOX Weekly FORMCHECKBOX MonthlyTerm (ie 10/SP) for Requested Equipment to be in Service: FORMTEXT ?????Is other equipment dependent upon this request? (Check One) Yes FORMCHECKBOX No FORMCHECKBOX If yes, please describe the equipment and how they are integrated. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????List programs , including the G.L.# and percentage of usage that will share this equipmentName of ProgramGL# to be Charged% Usage FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????C. Installation /Maintenance/WarrantyWhat special installation requirements are necessary for this request?Please include installation costs. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Special utility hook-ups (i.e. gas, water, heat, cooling, electricity, telephone) FORMTEXT ?????Remodeling needs (i.e. additional storage, room addition, etc.) FORMTEXT ?????3)Estimated annual maintenance cost $ FORMTEXT ?????4)Who will provide the maintenance for this equipment? FORMTEXT ????? FORMTEXT ?????Where are they located? FORMTEXT ?????INCOMPLETE FORMS MAY NOT BE ACCEPTED FOR REVIEW BY THE COMMITTEEORIGINATOR’S PRIORITY CODE :Choose From:1 - Required Need2 - Moderate Need3 - Nonessential Need CHECK ONE: 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX SIGNATURE OF ORIGINATOR _________________________________________________________________________DEAN’S PRIORITY CODE : Choose From:1 - Required Need2 - Moderate Need3 - Nonessential Need CHECK ONE: 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX SIGNATURE OF DEAN (APPROVAL) _____________________________________________________________________INDIAN HILLS COMMUNITY COLLEGESEE QUESTION A ON PAGE #1CONDITION OF EQUIPMENT BEING REPLACEDCHECK ALL THAT APPLY FROM:1 – Excellent2 – Good3 – Fair4 – Poor5 – Safety IssuePROPOSED DISPOSAL METHODNEW ITEM DESCRIPTIONESTIMATED COSTDESCRIPTION OF ITEM BEING REPLACEDTAG # OF ITEM BEING REPLACEDDATE PURCHASED12345 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? 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