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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 8/15/2017 <br />Name <br />Kyra Clark <br />Department <br />Adm & Fin <br />BPW Date <br />August 22, 2017 <br />Phone Extension <br />7678 <br />L)�g <br />Agreement <br />H Contract U Proposal Ll Addendum <br />® <br />Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />Quest Diagnostics <br />New Vendor <br />MBEIWBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />J Yes N No LJ If Yes, Approved by Purchasing <br />MBE ❑ WBE <br />Substance Abuse Testing Services Agreement <br />None <br />Liability Insurance Fund <br />226-0418-671-39-80 <br />$ See Exhibit A <br />Employee substance abuse testing services. Fee schedule attacehd. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination. Non -Debarment. E-Verifv. Iran. etc. <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: 0% <br />New Amount $ 0 <br />Total Percent of Change: 0% <br />Dispersal After Approval ` <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />