Format for Request for Exception date _____ Agency / Agency

							                                                     Agency Internal Tracking Number:




Format for Request for Exception                              Date:
(Governors Executive Order 2008-011)

Agency/Agency Code:

Brief Description:


Describe/attach reasons for the exception requested:
If this is for hiring exception provide:
            Job classification:
            Tool number:
            Perm number:
            Est. salary impact for each position to include fringe
            Benefits @ 30%:
            Date Position Vacant:
 If this is for re-class/create exception, complete the matrix and attach PAQ:         (for
  vacant positions use midpoint for salary)


                                                                           Total
         Position      Previous         New          Hourly    Benefits   Hourly   Annual
Name     Number      Classification Classification   Salary    @ 30%      Salary   Salary




If this is for purchase of equipment, provide:

Item #                  Description                     Qty      Unit        Item
                                                                 Cost        Cost
                                         Totals
                                                         Y      N
Replacement (Y/N)?
Expansion/Enhanced Capability (Y/N)?
Equipment for Certified Project?
Is the equipment acquisition in the agency IT Plan? Include summary.
 How does this purchase impact State infrastructure? Explain.
 Hardware/Software/Telecom equipment purchases requiring DoIT approval attach
  coordination/DoIT approval.
 If presently paying contractor indicate:
       o Costs incurred to date:
       o Timeframe for work to be done:
       o Future estimated cost:

Comments:

Justification/Program Impact:

Alternatives Considered:

Fiscal Impact: (Please indicate type of funding (GF, FF, OSF), appropriation affected)
            Description Upfront                      Recurring
                              FY07        FY08 FY09 FY010           FY11
Staff

Hardware

Software
NOTES:




Agency Contact(s) for Additional Information:
Approved By:

______________________                                Date: ____________
 [Insert Agency Cabinet Secretary/Agency Director Name]
 Secretary/Director of [Insert Agency Name]



______________________                               Date: ____________
[Insert Agency CIO Name]
Chief Information Officer for [Insert Agency Name]

__________________________________________________________________

                             FOR DOIT USE ONLY


“EXCEPTION” WORK GROUP RECOMMENDATION:
____________________________________________________________
____________________________________________________________
____________________________________________________________

DECISION BY CABINET SECRETARY, DEPARTMENT OF INFORMATION
TECHNOLOGY:



Date: ___________________

Approved/Disapproved ________________________________________________
                      Cabinet Secretary, Department of Information Technology
                      State Chief Information Officer