University of Pittsburgh Cancer Institute (UPCI)

Policies and Forms

UPCI Capital Equipment Request Form

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

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

The UPCI Capital Budget assures that all expenditures for fixed and major movable assets are based upon carefully planned institute-wide programs for development. Capital Expenditure is defined as any individual piece of durable equipment that costs $2,000 or more and has a useful life of at least 5 years.

Instructions for Completing and Submitting Form

  1. Please complete Sections I-IV.
  2. Please submit the completed form electronically and as 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:
    Program:
    Department of Primary Appointment:
    School of Primary Appointment
    Name of Equipment Requested:
    Source/Vendor:
    Quoted Cost ($):
    Installation Cost, if Applicable ($):
    Annual Maintenance Cost/Service Contract if Applicable ($):
    Where will the equipment be housed?
  3. Justification for Purchase
  4. Description and purpose of the item:
    NOTE: For Shared Facility purchases exceeding $50,000, please review the UPCI Policy for Capital Equipment Purchases.

    1. Description of the equipment's use and value to UPCI or the requestor's research program/department. Include operational improvements, productivity enhancements, and savings or increased revenue, etc., as applicable:

      255 characters remaining
    2. Equipment that has been used to serve this purpose to date and its location:

      255 characters remaining
    3. List of faculty you have identified who will use the requested equipment:

      255 characters remaining
  5. Funding Information
    1. This item 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

      255 characters remaining
    2. This item will be (check one box only):
      A replacement for existing common equipment*
      (*Note: If existing equipment will not be disposed of, then the new equipment being requested should be defined as 'additional equipment'.)
      New equipment
      Additional equipment**

      255 characters remaining
    3. Can the item 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 product
    • Quote from vendor
    • Sole Source Justification
    • Documentation of available funds (if to be paid through a restricted fund or other source)
    • Equipment Screening Certificate (required only for 05-accounts using a Federal grant to purchase a single piece of equipment valued at $5,000 or more)