HealthEast Purchasing Department

Equipment Checklist Form

Completion of this form is required by HealthEast prior to finalization of a purchase agreement. Your responses on this form will become part of the purchase agreement unless subsequently revised by an amendment authorized by a HealthEast buyer. Complete a separate form for each equipment model being proposed and submit with your quotation. Copy this form as necessary.

Department Requesting Equipment:______

Facility:______

Equipment Description:______

Supplier:______Supplier Representative:______

Phone :______Date Submitted:______

Quotation #:______Date Expires:______

HealthEast Purchasing Department

1700 University Avenue

St. Paul, Minnesota 55104

Phone: 651-232-1369

Fax: 651-232-1082

This form must be completed for all patient care equipment and capital purchases


General Information

  1. Describe the equipment being proposed:
  1. Equipment description

a.Manufacturer:______

b.Model:______

2.Equipment list price:$______

3.Quoted price:$______

  1. Manufacturing status of proposed model:______
  1. Domestic introduction date:______
  1. Original equipment manufacturer:______

7.Is this same equipment sold under a different name?: [ ] No [ ] Yes

If yes, please list other names and models:

______

______

  1. What are the voltage and phase requirements?
  2. Does the equipment have Underwriters Laboratory approval?

[ ] No [ ] Yes

  1. Does the device have a 3 wire AC line cord with hospital grade plug?

[ ] No [ ] Yes

  1. Will there be any additional accessories or parts that will be needed before the equipment can be put in to service? [ ] No [ ] Yes

If so list these items and pricing.

______

______

______

B.The quoted price will remain effective until:______
C.When do you anticipate your next price increase?:______
  1. Will the price as quoted above be the total financial commitment for this purchase?:

[ ] Yes[ ] No If no, please explain:

______

______

______

  1. Will any additional parts or accessories needed to install the equipment, and make it operate properly, be at the expense of the vendor?

[ ] Yes[ ] No If no, please state responsibility:

______

______

______

F.What is the trade-in value of our used equipment?:______

Description of trade-in:______

G.What would it cost to lease this equipment from your company? $______

[ ] Lease proposal attached

Delivery / Installation Information

A.What is the delivered freight cost: $______
B.Who is responsible for freight cost?:______
  1. Vendor will assume responsibility for resolving any damage claims related to the order at their expense including shipping.

[ ] Yes[ ] No If no, please explain:

______

______

______

D.What is the delivery lead time of the equipment: ______/Days
E.What is the time needed for installation?: ______/Days
F.Will HealthEast’s BioMed department be involved in the installation?

[ ] Yes[ ] No

If Yes, please describe involvement:

______

______

______

G.Will all the equipment be shipped at the same time?

[ ] Yes[ ] No If no, please explain:

______

______

______

  1. Will a vendor representative be responsible for receiving the equipment and completion of an equipment checklist prior to installation?

[ ] Yes[ ] No If no, please explain:

______

______

______

I.Equipment checklist must be provided to the HealthEast Purchasing Department buyer upon receipt and inspection of the equipment. This is necessary for invoice approval.

[ ] Yes[ ] No If no, please explain:

______

______

______

  1. Physical dimensions of equipment (inches/feet):

______Width - ______Depth - ______Height

  1. Equipment weight:______
  1. Power requirements:______
  1. Power consumption:______
  1. Does this equipment have a power surge protector?:

[ ] Yes[ ] No If no, please explain:______

  1. Does the equipment require an Uninterrupted Power Supply (UPS)?

[ ] Yes[ ] No

If Yes, is it provided?[ ] Yes[ ] No

J.Vendor must provide two (2) operating manuals, two (2) service manuals, pertinent electrical and mechanical schematics, and a current parts list. These items must be shipped to HealthEast’s Purchasing Department.

[ ] Yes[ ] No If no, please explain:

______

______

______

K.Is there a place for the equipment when it arrives?

[ ] Yes[ ] No If no, please explain:

______

______

______

L.Is renovation of the site required prior to installation?

[ ] No[ ] Yes If yes, please provide detailed description and estimated cost:

______

______

______

M.Vendor will assume responsibility for uncrating equipment upon delivery and removal of packing materials from the premises.

[ ] Yes[ ] No If no, please explain:

______

______

______

N. Will this equipment require any unloading equipment at the time of delivery?

[ ] No[ ] Yes If yes, please specify:

______

______

______

Warranty & Maintenance Information

A.What is the average meantime between equipment failures:______
B.Who will service the equipment during the warranty period?:______
C.Will HealthEast’s BioMed department perform “First Look” maintenance?

[ ] No[ ] Yes If yes, please specify:

______

______

______

D.What is the procedure for requesting service:______

______

E.What is the standard warranty period on the equipment? ______/Months
F.Does the Warranty include parts & labor?

[ ] Yes[ ] No If no, please explain:

______

______

G.When does the warranty period begin?______

______

H.Do you offer service / maintenance agreements on this equipment?

[ ] Yes[ ] No If no, please explain:

______

______

  1. Vendors should include a quotation for a one (1) year service / maintenance agreement following expiration of the warranty.

[ ] Attached[ ] Not attached, please explain:

______

______

  1. Current annual service contract cost: $______
  1. Service point of origin:______

3.Service Telephone Number: ( ) ______

  1. Describe the service provided under the warranty (unless indicated otherwise, we will consider warranty service coverage to be 24 hours a day, seven days a week).

______

______

Vendor agrees to provide training for HealthEast’s BioMed department staff on the repair of the equipment at no additional cost.

[ ] Yes[ ] No If no, please explain:

______

______

Other

A.Are any supplies or consumables necessary for the utilization of this equipment?

[ ] No[ ] Yes

If yes, attach a separate quotation with one (1) year firm price, or indicate the vendor (s) available from, and suggest a start-up quantity:

______

______

B.Will upgrades be required or available within one year? [ ] Yes [ ] No

______

Who is responsible for the costs of upgrades?______

C.Will an in-service on the use of this equipment be required?

[ ] No[ ] Yes If yes, state specifics:

______

Note: It will be the vendor’s responsibility to coordinate all in-service activities with the appropriate HealthEast staff. HealthEast’s BioMed staff must be in-serviced on the equipment within 48 hours of installation and/or delivery of all patient care equipment.

Reference Information

Provide References of Three (3) Customers in the Minneapolis / St. Paul Area:

  1. Company:______

Contact Person:______

Phone Number:______Installation Date:______

Installed Equipment:______

  1. Company:______

Contact Person:______

Phone Number:______Installation Date:______

Installed Equipment:______

  1. Company:______

Contact Person:______

Phone Number:______Installation Date:______

Installed Equipment:______

Please submit any additional information that you feel HealthEast should consider in making this selection. [ ] Attached

Signature:______Title:______

Date:______

Thank You!

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