Vac Form| Blanchard Valley Health Services

VAC No:

Instructions: Please complete the attached form completely for evaluation by Value Analysis Committee.

Section A - Requestor's Information

Requestor:

Presenter:

Requestor Email:

Presenter Email:

Department:

Telephone Number:

If yes fill out Sections B & C. No, move to Section C.

Section B - CURRENT Product Information

Name and Description of Current item:

Vendor:

Unit of use:

Manufacturer Item No:

Cost per unit of use:

ERP Number:

Annual usage by unit of purchase:

EOC:

124

152

076

If EOC 124 or 076 enter charge code: