ࡱ>  tAbjbj ZËË *****>>>8vtL>!6X***|' (|)@dffffff$kQ*D)Z'Z'"D)D)****0 ۲+++D)F****d+D)d++LT*Pq})ܥZP0!6 )B T *TD)D)+D)D)D)D)D)*D)D)D)!D)D)D)D) D)D)D)D)D)D)D)D)D) : FORM C: TECHNOLOGY REQUEST CONTRACT-COSTING CHECK To be completed by Contract/Costing Expert (CPSM) Name of Applicant:  FORMTEXT      (Office use only) EDSP ID:  FORMTEXT      Department:  FORMTEXT      Division:  FORMTEXT      Phone:  FORMTEXT      Email:  FORMTEXT       Pager:  FORMTEXT      A-1. Name of proposed technology (or trade name if applicable):  FORMTEXT       Contract/Costing Expert will determine: if there are any legal or contractual issues with Form A: Technology Request if there are cost concerns whether a Request For Proposal (RFP) is required if the Technology Request represents a simple change of vendor If the Contract/Costing expert feels that there are issues with the Request or that further information is required, then the expert may recommend a Local HTA (See Appendix I: Technology Assessment Screening Guide). C-1. Is the technology Health Canada Approved:  FORMCHECKBOX N/A  FORMCHECKBOX  No  FORMCHECKBOX  Yes C-2. Are there any legal or contractual issues with this request?  FORMCHECKBOX  No  FORMCHECKBOX  Yes C-3. Does the item require a Request For Proposal (RFP)?  FORMCHECKBOX  No  FORMCHECKBOX  Yes C-4. Is the item or a similar item already on purchase contract?  FORMCHECKBOX  No  FORMCHECKBOX  Yes If Yes, is the change budget neutral?  FORMCHECKBOX  No  FORMCHECKBOX  Yes C-5. Are there significant cost concerns with this request?  FORMCHECKBOX  No  FORMCHECKBOX  Yes C-6. Costing: Please provide detailed costing assessment for this request compared to current practice, and indicate if there are any cost concerns:  FORMTEXT       C-7. Comments Please provide any additional comments that need to b6bd     : D N ں{eQB0#hIkhSr;5B*CJ\aJphh0f15B*CJ\aJph&hIkhSr;56B*CJ\aJph+jhIkhSr;CJU\aJmHnHu&jhIkhSr;CJU\aJhIkhSr;CJ\aJ jhIkhSr;CJU\aJhIkhSr;5CJ\aJh'CJOJQJ^JaJ#h0f156CJOJQJ\^JaJ#h'56CJOJQJ\^JaJ h'>*\ h'6\ h'\d v x Hykd$$Ifl0d'h t044 laytIk $IfgdSr;$a$/$$d%d&d'd-DM NOPQa$N P d f h r t v ꔆuiUu?uui+jhIkhSr;CJU\aJmHnHu&jvhIkhSr;CJU\aJhIkhSr;CJ\aJ jhIkhSr;CJU\aJhIkhSr;5CJ\aJ#hIkhSr;5B*CJ\aJph4jhIkhSr;B*CJU\aJmHnHphu/jxhIkhSr;B*CJU\aJph hIkhSr;B*CJ\aJph)jhIkhSr;B*CJU\aJph      & ( : < P R T ^ ` t v  " 6 ۷ۜ۷ۜt۷ۜ`۷ۜ&jhIkhSr;CJU\aJ&jVhIkhSr;CJU\aJ&jfhIkhSr;CJU\aJhIkhSr;CJ\aJhIkhSr;5>*CJ\aJhIkhSr;5CJ\aJ+jhIkhSr;CJU\aJmHnHu jhIkhSr;CJU\aJ&jhIkhSr;CJU\aJ! * , f ikd$$IflF d'h h h t0    44 laytIk $IfgdSr; H | $IfgdSr;ykdF$$Ifl0d'h t044 laytIk6 8 : D F J L   j m p N Z  ۼsj^OA^h:h'56CJaJh:h'56CJ\aJh:h'CJ\aJhSr;CJ\aJhSr;h'5CJ\aJhSr;hSr;CJ\aJhSr;h'CJ\aJh'6CJ\aJh'CJ\aJh'CJOJQJ\^JaJhIkhSr;5CJ\aJ jhIkh!ZCJU\aJ jhIkhSr;CJU\aJ&jhIkhSr;CJU\aJH J L  7 j tg 0dh^`0 edh^e` & F  0^`0hkdD$$IflM'8( t044 laytIk =>LMNOQ{p^#j"h'5CJU\aJh'5CJ\aJ)jh Ch?295CJU\aJh!5CJ\aJ)j6h!ZhG`5CJU\aJ)jh!ZhG`5CJU\aJjh'5CJU\aJh0f15CJ\aJha=5CJ\aJhQG5CJ\aJh'5CJ\aJ$QTUcdefijmn'{papjh65CJU\aJh65CJ\aJh:h65CJ\aJ#jh'5CJU\aJ#jh'5CJU\aJh:h'5CJ\aJh:h:5CJ\aJh!5CJ\aJ#jh'5CJU\aJjh'5CJU\aJh'5CJ\aJ jE<tv001 $Ifgd4^gdk e^e`gdtK^gdSr; e^e` dhgd k & F)dhgdtKdhgd6dh '()*,/0>?@ADEmstӶӪlȁWȁLh:5CJ\aJ)j\ h kh65CJU\aJ)j h kh65CJU\aJh kh65CJ\aJ#jh kh65CJU\aJh kCJ\aJhtKh6CJ\aJ#jp h65CJU\aJh!5CJ\aJh65CJ\aJjh65CJU\aJ#jh65CJU\aJ(68:<Zjl|$~vnvfvfZfRhQGCJaJhsuhbP>*CJaJhbPCJaJhtKCJaJhSr;CJaJh'5CJaJh'5CJ\aJh:hSr;5CJ\aJh:h'5CJ\aJh'CJ\aJ#jH h k5CJU\aJh!5CJ\aJ#j h k5CJU\aJjh k5CJU\aJh k5CJ\aJ$,FHLNbdfprtv0D0T0h0j0l0000000ƴџ|qj\qKqD hkh' jhqh'UmHnHuj6 hqh'U hqh'jhqh'UhkUh'CJaJh'5CJaJ *htK5CJ\aJ(jhqhkCJUaJmHnHu#j hqhb:CJUaJhqhkCJaJjhqhkCJUaJhkCJaJhSr;CJaJhQGCJaJh(5RCJaJe brought to the attention of the advisory committee  FORMTEXT       Contract/Costing Expert SIGNATURE:  FORMTEXT       (or designate) ( signature and pdf file submission is recommended) PRINT NAME:  FORMTEXT       DATE:  FORMTEXT        Submit completed Forms A-C to the SSCN-EDSP Advisory Committee for review E-mail  HYPERLINK "mailto:paule.poulin@albertahealthservices.ca" paule.poulin@albertahealthservices.ca     PAGE 0000011 1111>1B1D1J1L1111111224262J2ѽݧݘьрrdPݧ&jhIkhTCJU\aJhIkhT6CJ\aJhIkhq6CJ\aJhIkhqCJ\aJhIkhXCJ\aJhIkhT5>*CJ\aJ+jhIkhTCJU\aJmHnHu&j hIkhTCJU\aJhIkhTCJ\aJ jhIkhTCJU\aJhIkhT5CJ\aJh'1111 2$hkd $$Ifl'8( t0644 laytIk $Ifgd4jkd" $$Ifl'8( t0644 laytIk 2 2^2`2"jkd$$Ifl'8( t0644 laytIk $Ifgd4jkd$$Ifl-'8( t0644 laytIkJ2L2N2X2Z2\2`2b2d2p22222223۶rdUdrGd2(h0f1h'CJOJQJ^JaJmH sH h[DcCJOJQJ^JaJh'6CJOJQJ^JaJh'CJOJQJ^JaJh0f1CJOJQJ^JaJ<h'CJOJQJ^JaJehfHq rh'CJ\aJhIkhT5CJ\aJhIkhT5>*CJ\aJ+jhIkhTCJU\aJmHnHu jhIkhTCJU\aJ&j hIkhTCJU\aJ`2b2d2233333333333333@@@h]h&`#$$a$gdj4 h$d%d&d'd-DM NOPQ^h33.3t3|3~333333333333333333334@@דvnjnjnjnjfj]YOIGOU hr0Jjhr0JUhrhr6CJaJh!ih.gjh.gUh0f1h'mH sH "h0f1h'5CJ\aJmH sH .h0f1hsu5CJOJQJ\^JaJmH sH ,hx+5h0f10JCJOJQJ^JaJmH sH (h0f1h0f1CJOJQJ^JaJmH sH "h0f1CJOJQJ^JaJmH sH +jh0f1CJOJQJU^JaJmH sH  Local HTA Decision Support Program Page  PAGE 2 of  NUMPAGES 36 2009 Revision: Final  Surgery SCN EDSP: Form C (Revised Dec. 2014) Page  PAGE 1 of  NUMPAGES 1 @@@Z@\@h@j@l@n@v@x@@@@@@@@@@@@@@@ Aٽٯwea]QHh!i6CJaJhb hb 6CJaJh!Zhb "jhb UmHnHsH tH uh[qhrCJaJh[6CJaJ hj0J6CJaJmHnHu$jh[qhr0J6CJUaJh[qhr0J6CJaJhj0JCJaJmHnHuh[qhr0JCJaJ!jh[qhr0JCJUaJh[qhr6CJaJhr hr0J@@@@@@lAnApArAtAgdjgdb   !$h]h A"A0A2A>A@ABADALANAdAfAhAjAlAnApArAtAֵֵ걭h0f1h'mH sH h.gh,h0f1"h!i56CJ\aJmHnHuhb hb 56CJ\aJ&jhb hb 56CJU\aJhb hb 6CJaJhb 6CJaJB 00P1h:pj/ =!"#8$% Dpn9˟~USPp3 PNG  IHDRrfsRGB pHYs:PLTEqu}y}}yu}}}{s{s{ss{s{{sk)1)!119!1!!9119)1)!!!)9Ì9ǔ9Ô1Ô)Ô1ÌBJJBBBZZRJRRJRZJǜJ˜BǜBǔR˜BÔJǔRǜZϥZϭR˥Z˥J˥{ckskk{css{s{{s׵sӵkӭ{׽{׵cϥcӭcϭkӵ{۽猾焺۽߽׽۽ƜƌƔΔΥޭֵ֥֥Υεֵ`N$IDATx흋[mD+RYMSiI9OS5ڦ`(HI!Ū dCofLTHǙ}.of㴍I$g$g$g$g3Ybܒ["/6&H͑GY>1%Bq//̧͔(ǯ˩yP(䫳湚ֱμ<֒3/=c-9Sμ<֒3/=c-9Sμ<֒3/=c-9Sμ<֒3/=c-9Sμ<֒3/=˷DrssǩH?5|Jz={h0ޯG(X 3xW9h6G-6Cq=^zZ׷^*4rxau/E7X @G<𾣺}s)t95qv,Xuk^#Q[{vG?ᴞz@d-$T{wG*RMO^\B$ې 1:庅ս;-J(ܾ]Z]kMZ7 W펅)GGOdĂP~,:{(  ݼ>IyHy3PnI W(5#P3g7 E3,>Qy]@= xc#P~9y#=wxPʛWArcJc厷%Ҥ)B>ˏ5S\R=.ДWRNi11;9BGɬC0W套](A^n*x\|jFPx+"US^^}t'*Dy\SlRw,jW|UlX=ZX4>1.^c4/.xiZoBytp/OۑnAvL*B?HoRޏ$c3.>GKF nOH|ؓtd#ԴW%ŁMr<9la^.XY@5{,de )mӭŻc ^0](7G'{DZF'|#R</~86zw?/7I^{)1Qg55%CRwsԕ?: |H2fhe-{D<:8"QXfθPNܝ+n ,a^^8 OWX9adCS_*?;g #-mo:I2 U fhkBqM[iOءd7¼y1W`z@yʼJo҃LU8tkL >ź _ Zih\ޗ7 y/? 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