Digital CARD 11062018

Contract Approval Request Drawdown Form

HBS Procurement - Sourcing & Contracting
1. Introduction:
Project Title:
Insert Equipment/Service for Location.
Project Number:
Insert Project number relevant to this CARD only.
Select HBS Procurement Approver:
Insert Budget Holder Name & Title:
If not requried, insert N/A.
Insert Budget Holder Email
If not required, insert N.A.
Select HBS Procurement Assistant Head:
Select HBS Procurement Category Specialist:
Date:

DayMonthYear
Please select Date of Submission, i.e. DD/MM/YYYY

Contract Approval Request Drawdown Form

HBS Procurement - Sourcing & Contracting
2. Executive Summary of Outcome & Process Overview:
Once-Off, i.e. once project is completed/awarded, no other input will be required until submission of a new PSR.Recurring, i.e. contract will need to be scheduled for renewal on expiry on original contract.
Recommended Awarded Company:
Insert Full Company Name as per Tender Document.

Spend:

Rows	Total € Spend Value over Lifetime:
Capital incl. VAT:
Maintenance incl. VAT:
Consumables incl. VAT:
Total incl. VAT:

Once-Off Benefit Purchase Savings:

Rows	Once-Off € Benefit Value:
Additional Discount to Tendered Goods:
Complimentary Goods/Service Value:
Current Costs of Goods vs PO Value:
Budget vs PO Value:
Total Once-Off Benefits:

Continuing Operational Savings/Costs:

Rows	Maintenance € Savings/Costs incl. VAT:	Consumables € Savings/Costs incl. VAT:	€ Total incl VAT:
Year 1:
Year 2:
Year 3:
Year 4+:
Totals:

Any Continuing Operational Costs i.e. negative impact on current expenditure, please use minus sign, e.g. -300
Total € Savings/Costs:
Total of Once-Off Benefits + Continuing Operational Savings/Costs
Methodology on Calculation of Savings/Costs:
Please detail Savings/Costs Methodology here. If non-applicable enter N/A.
Please provide Project Reference & Title of Parent Contract:
Please provide Project Reference & Title of Equipping Contract:
If non applicable please enter N/A.
Please detail the Drawdown Provision that was made in Original 'Parent' Contract:
Insert Wording used in Parent Contract that allows for of the Drawdown.
Please detail the number of Drawdowns from Original 'Parent' Contract:
Specify the number of Drawdowns inclusive of this one.

Contract Approval Request Drawdown Form

HBS Procurement - Sourcing & Contracting
3. Brief Explanation of Award & Proposed Contract Term:
Brief Explanation of Award:
If Once-Off, please provide estimated Date of Draft Order Placement:

DayMonthYear
If Recurring, please complete the below:
Estimated Contract Effective Date for this CARD only:

DayMonthYear

Please note that the calculation for Value of Contract, savings and renewal date of contract on the PPMS are based on the start date provided above; therefore if the dates of the contract change, please email procurement.support@hse.ie
Original Contract Ref:
Start Date:

DayMonthYear
End Date:

DayMonthYear
Contract Extension Ref:
Start Date:

DayMonthYear
End Date:

DayMonthYear

Rows	Contract Duration in Months for this CARD only:	Extension Period in Months for this CARD only:
Term:

Contract Approval Request Drawdown Form

HBS Procurement - Sourcing & Contracting
4. Confirmations & Recommendations:
The Procurement Team recommends the award of this contract as detailed above and confirms:
1. The procurement process detailed above complies fully with Statutory Instrument No. 284 of 2016 EUROPEAN UNION (AWARD OF PUBLIC AUTHORITY CONTRACTS) REGULATIONS giving effect to Directive 2014/24/EU of the European Parliament and of the Council of 26 February 2014 on public procurement and repealing Directive 2004/18/EC, HSE Procurement Policy; and HSE National Financial Regulations.
2. No member of the Evaluation Team or anyone else involved in the above procurement process had any registered interest or conflict with any of the tenderers.
3. Award of contract(s) is subject to the receipt of satisfactory tax and insurance certificates.
4. [Where appropriate] All personnel involved in the provision of the service will be subject to Garda Security Clearance.
5. Award of contract will be governed by legally binding contracts which protect HSE interests. The contract will include appropriate confidentiality clauses.
6. Funding is availabel to meet the cost of this contract.
7. Total life cost analysis has been carried out and the recommended contract represents best value for money.
8. [Where appropriate] The recommended contract has been reviewed and approved by CMOD as part of the peer review mechanism put in place by Government.
9. The business benefits identified will be tracked to ensure that they are realised and will in due course be available to Board/CEO/National Director etc and C&AG.
10. A contract will not be concluded within the standstill period required under European Communities (Public Authorities's Contracts) (Review Procedures) Regulations 2009.
Submitted by:*
Submitter's Email:*
Insert Email of Submitter.
- As Reviewer, enter your name:*
- Reviewer Approval:*
- I have read and reviewed the above information.
- As Recommender, enter your name:*
- Recommender Approval:*
- I have read and reviewed the above information.
- As Approver, enter your name:*
- Process Approval:*
- I have read and reviewed the above information.
- Should be Empty:

Contract Approval Request Drawdown Form

1. Introduction:

Contract Approval Request Drawdown Form

2. Executive Summary of Outcome & Process Overview:

Contract Approval Request Drawdown Form

3. Brief Explanation of Award & Proposed Contract Term:

Contract Approval Request Drawdown Form

4. Confirmations & Recommendations: