University of Pittsburgh Cancer Institute (UPCI)

Policies and Forms

UPCI Purchased Services Request Form

Use this form to request the purchase of any purchased services costing $2,000 or more.

PLEASE PROVIDE AT LEAST 30 DAYS NOTICE TO PROCESS THIS REQUEST.

The UPCI Operating Budget assures that all major expenditures for purchased services are based upon carefully planned institute-wide programs for development. Major Expenditure is defined as any purchased services agreement that costs $2,000 or more. Purchased Services include Consulting Services, Contracted Services, Testing Services or any other Professional Services provided by sources outside of the University.

Instructions for Completing and Submitting Form

  1. Please complete Sections I-IV.
  2. Please submit the completed form electronically and as a hard copy:
    • Electronic Submission:
      • Click the 'Preview & Confirm (Electronic)' button at bottom of completed form.
      • You will be asked to confirm your information before final submission. To make changes, simply change the information in the appropriate field(s).
      • When all information is correct, click 'Submit & Generate PDF'.
      • After submitting electronically, a copy of the PDF will be emailed to the address you provided. Save the file and print a copy of the completed form.
    • Hard Copy Submission:
      • Click the 'Preview & Confirm (Hard Copy)' button at bottom of completed form.
      • You will be asked to confirm your information before final printing. To make changes, simply change the information in the appropriate field(s).
      • When all information is correct, click 'Printable Version'.
      • Secure any attachments required in Section IV to the printed copy of completed form.
      • A signatures section (Section V) will be included on your printed copy. Signatures in Section V are not the applicant's responsibility but this page should be included with submission.
      • Send form and all attachments to:
        Joan Neitznick
        Administrator for Basic Research
        Suite 1.25
        Hillman Cancer Center Research Pavillion
  1. General/Cost Information
  2. First Name:
    Last Name:
    Email:
    Phone Number:
    Department of Primary Appointment:
    School of Primary Appointment:
    Purchased Services Requested:
    Source/Vendor:
    Quoted Cost:
    Purchased Services to be Provided:
    255 characters remaining
  3. Justification for Purchase
  4. Description and purpose of the item:

    1. Description of the purchased services' use and value to UPCI or the requestor's research program:

      255 characters remaining
    2. Is this service provided by any UPCI or University shared facility?
      Yes* No

      *If yes, please explain why you are not using the shared facility.

      255 characters remaining
  5. Funding Information
    1. This purchased services agreement will be used (check one box only):
      Exclusively by my research lab
      As common equipment for use by all UPCI faculty and staff
      As a part of UPCI Shared Facilities
      By a group of faculty* who are pooling resources for its purchase
      *Please list faculty members:

      255 characters remaining
    2. This purchased services agreement is (check one box only):
      A renewal of an existing purchased services agreement
      A replacement of an existing purchased services agreement
      A new purchased services agreement
    3. Can the item be included in the next year's budget (i.e., to be purchased after the coming July)?
      Yes No
    4. Available sources of funding (check all items that apply):
05 Grant Funds:
Yes

No

N/A
Amount($):
Account #:
04 Restricted Funds:
Yes

No

N/A
Amount ($):
Account #:
02 Restricted Funds:
Yes

No

N/A
Amount ($):
Account #:
02 Hard Funds:
Yes

No

N/A
Amount ($):
Account #:
Start-up Funds:
Yes

No

N/A
Amount ($):
Account #:
Other: Description
Account #:
  1. Attachments
  2. Please secure the following attachments (as applicable) and submit to Joan Neitznick as described in the instructions.

    Joan Neitznick
    Administrator for Basic Research
    Suite 1.25
    Hillman Cancer Center Research Pavillion