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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10/14/2020 <br />Department <br />Name Charlotte Brach Engineering <br />BPW Date 10/27/2020 Phone Extension 9246 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ Officer Name <br />and Inclusion Officer <br />BPW Attorney <br />❑ Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />Check the Appropriate Item Type — Re uired or All Submissions <br />❑ Professional Services Agreement ❑ Contract ❑ Proposal <br />❑ Open Market Contract ❑ Amendment/Addendum ❑ Special Purchase, QPA <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award ❑ Reject Bids/Quotes <br />❑ Proposal Opening ❑ C/O & PCA No. ❑ PCA <br />❑ Chg. Order, No. ❑ Traffic Control ❑ Resolution <br />17 Other: Agreement n Ease./Encroach <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Information <br />I�[K6Z611 <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />❑ No <br />F] MBE ❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />MACOG MOU for Traffic Data Collection <br />N/A <br />LRSA — PR-00004758 <br />251-06-600-506-442001 <br />$28,000 <br />Traffic count data collection by MACOG for City of South Bend. See <br />attachment for a list of sites. <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Increase % <br />Decrease ( % <br />Increase % <br />Total Percent of Change: Decrease ( % <br />Time Extension Amount: <br />New Completion Date: <br />