UPMC Hillman Cancer Center

Policies and Forms

Hillman Service Agreement Request Form

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

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

The Hillman Operating Budget assures that all expenditures for service agreements are based upon carefully planned institute-wide programs for development. Major Expenditure is defined as any service agreement that costs $2,000 or more.

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:
    Service Agreement Requested:
    Source/Vendor:
    Quoted Cost:
    Equipment Covered:
    255 characters remaining
  3. Justification for Purchase
  4. Description and purpose of the item (Description of the service agreement's use and value to Hillman or the requestor's research program):

    255 characters remaining

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

      255 characters remaining
    2. This service agreement will be (check one box only):
      A new service agreement
      A renewal of an existing service agreement
      A replacement of an existing service agreement
    3. Can it be included in the next year's capital 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.

    • Vendor's description of service agreement
    • Quote from vendor
    • Sole Source Justification
    • Documentation of available funds (i.e., gift accounts, restricted or unrestricted funds)

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