Project Management Contract Modification

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Project Management Contract Modification Powered By Docstoc
					                                                                                                                                                           Rev. 8/31/06
                                                                                                                                                            DM #21408



                                                                CONSULTANT SERVICES
                                                           CONSULTANT FINANCIAL SCREENING
                                                         CONTRACT / MODIFICATION REQUEST FORM

  DATE:


  TO:         Hank Bryan, Consultant Services Financial Analyst, hbryan@utah.gov
              << , Contract Administrator, << @utah.gov


  FROM:       << , << Project Manager, << @utah.gov


                                                                      PROJECT MANAGER SECTION
  PIN No:                                                         Job/Proj (CID No):                                                 Est $ Amt.
  Project No:                                                     Contract No:                                                       Mod No:
  STIP Project Location (req) :
  Brief Scope Description (req) :


  Fee Type:                                             Unit Price                       Lump Sum                    Cost Plus Fixed Fee                      On Call
  Consultant Selection Type:                               Pool                       Standard RFQ                    Streamlined RFQ                   Engineer of Record
  Pool - Period                                       2005 - 2007                       2003 - 2005                       2001 - 2003                    Other
  Pool:                                                 G E Pool                          L G Pool                            Other                          (Specify)

  Pool:                                                  PM Pool                       CE Mgmt Pool                     Structures Pool
  Pool Discipline (req) :
  RFQ - Proposed Selection Team:


  Consultant:                                                                       Local Government Entity:
  Proj Contact Name:                                                                Project Contact Name:
  Contact Title:                                                                    Contact Title:
  e-mail Address:                                                                   e-mail Address:
  Phone No:                                                                         Phone No:
                                                                    FINANCIAL SCREENING SECTION
  Fringe Benefit OH Rate:                    0.00%                                  Pool $ Available - After this project:
  G & A OH Rate                              0.00%                                  Financial Screening Exp Date:
  Approved Total OH Rate:                    0.00%                                  Federal Tax ID Number:
  Eligible for Proj Over $250,000:                         Y/N                      Fixed Fee Rate:                                                  9 - 12 %
                                             2005-2007 Pool Score for this Consultant in this Discipline.
  Comments:
  Boiler Plate Change Required:
                                                                     REQUEST FORM INSTRUCTIONS
1) Project Manager initiates form, completing as much information in the top section as possible regarding the Consultant they would like to select for the project.
2) Project Manager then e-mails form to Hank Bryan and waits for financial screening verification before contacting the Contract Administrator or Consultant.
3) Rae will approve the selected consultant by completing the FS section of this form and returning it to the Project Manager, or she will notify you of any problems.
4) Project Manager prepares the items listed below, if applicable, and submits them to the Consultant Services Contract Administrator with this completed form.


                Scope of Work                                                                    ePM 505 Funding Screen print out
                Independent Cost Estimate (ICE)                                                  Financial Screening Request




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                                                                                                                                                          Rev. 6/30/06




                                                                   CONSULTANT SERVICES
                                                                  CONTRACT / MODIFICATION
                                                              PROJECT MANAGER APPROVAL MEMO

DATE:       <<date


TO:           << , Contract Administrator, << @utah.gov


FROM:       << , << Project Manager, << @utah.gov



PIN No:                                                       Job/Proj (CID No):
Project No:                                                   Contract No:                                                                 Mod No:
STIP Project Location (req) :
Brief Scope Description (req) :


Fee Type:                                           Unit Price                           Lump Sum                         Cost Plus Fixed Fee                 On Call
Consultant Selection Type:                             Pool                           Standard RFQ                         Streamlined RFQ              Engineer of Record
Pool - Period                                     2005 - 2007                           2003 - 2005                            2001 - 2003                      Other
Pool:                                               G E Pool                                L G Pool                                Other                    (Specify)

Pool:                                               PM Pool                            CE Mgmt Pool                          Structures Pool         Fixed Fee %
Pool Discipline:


Consultant:                                                                      Local Government Entity:
Proj Contact Name:                                                               Project Contact Name:
Contact Title:                                                                   Contact Title:
e-mail Address:                                                                  e-mail Address:
Phone No:                                                                        Phone No:


Contract / Modification Project Completion Date:
Contract / Modification Approval Amount ($):
Comments:




                                          Project Manager to complete red fields before submittal to Consultant Services
                                  THIS FORM IS CERTIFYING THAT THE UDOT PROJECT MANAGER HAS REVIEWED AND APPROVED
                                                THE FOLLOWING CONTRACT / MODIFICATION CONSULTANT DOCUMENTS:


             Local Government Review Memo (if Applicable)                                    Project Specific Insurance Certificate(s)
             Contract Approval Memo                                                          Cost Proposal
             Executive Summary                                                               Sub Consultant(s) Work Plan & Cost Proposal
             Work Plan / Scope of Work                                                       Independent Cost Estimate
             Quality Control / Quality Assurance Plan & Checklist                            ePM 505 Funding Screen print out
             Staffing Plan                                                                   R-709 Form (Federal & State Projects)
             Work Schedule                                                                   Cooperative Agreement (If Applicable)




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                                                                                     Page 2
To:            Division Administration                                                                                                             Rev. 6/30/06
               Federal Highway Administration
      Code     Salt Lake City, Utah                                               UTAH DEPARTMENT OF TRANSPORTATION
From:          Office Policy & Systems Planning                                         REQUEST FOR FEDERAL AID
      07-PS    Utah Department of Transportation                            PROJECT APPROVAL, AUTHORIZATION and/or AGREEMENT
  Return
 copies to:


                  PIN No:                                          STIP Ref. No:                                                  Year:
                  Project No:                                      Route:                                                        Job/Proj #:

                  County No:                                       County:                                                        Region:
                  STIP Project Location (req) :                                                                                   NBIS Inventory No:
                  Brief Scope Description (req) :



                  Authorization is requested in accordance with the procedure checked below:
                                Regular Federal Procedures                                                    Stewardship (Non NHS/Low Cost NHS)
                                Other:                                                                        Stewardship (NHS 3R Project)

                  Authorization is required to proceed with the work checked below:
     This
                           Preliminary Engineering                                 Right of Way                                     Construction
 Section is
    to be                      Environmental                                    Appraisals                                        Utilities (see remarks)
 completed                      Preliminary Design                              Acquisition                                       Advertise for bids
   by the
  division                      Preparation of plans,                           Type                                              Force Account
 originating
                                specification & estimates                       Relocation Assistance                                          Unit Price
the request
                                                                                Type                                                           Actual Cost
                                Consultant                                      Other:                                            Consultant

                                          Contract No:                                         Mod No:
                                          Consultant:
                  The scope of work and ICE were prepared by:
                  The approximate contract amount is:
                  and reviewed by Consultants Services on:

                 Remarks




                  Programming Clearance (Amounts for this Authorization)
For Fiscal
Planning          Program:                                                                                                        APPR
    &                                                                                                                             Code:
Program-          Total Funds:                           Federal Funds:                           State Funds:                    Other Funds:
ming Use

PRORATA:

                  Programming Coordinator:                                                                                        Date:


                                You are authorized to proceed with the above requested work.                            FHWA Electronic Signature:
    For                         Authorization for Expenditure and/or Project Agreement
  Federal
 Highway         Remarks
 Administ-
ration Use



                  R-709 Distributed by UDOT Comptroller Office                                    Initial:                        Date:


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                                                                                   Page 3
                                                                                                                                        Rev. 6/30/06




                                                     LOCAL GOVERNMENT
                                                 PROJECT MANAGER REVIEW OF
                                              CONTRACT / MODIFICATION INFORMATION

                                                                                              Local Government Contract Administrator
DATE:     <<date                                                                              Consultant Services
                                                                                              Utah Department of Transportation
TO:       << , << Project Manager, << @utah.gov                                               PO Box 148490
                                                                                              Salt Lake City, Utah 84114-8490
FROM:     << , << Local Goverment Project Manager, << @ << . <<                               801/965-4183


PIN No:                                                  Job/Proj (CID No):
Project No:                                              Contract No:                                                  Mod No:
STIP Project Location (req) :
Brief Scope Description (req) :


Fee Type:                                    Unit Price                          Lump Sum                  Cost Plus Fixed Fee              On Call
Consultant Selection Type:                        Pool                        Standard RFQ                  Streamlined RFQ         Engineer of Record
Pool - Period                               2005 - 2007                         2003 - 2005                    2001 - 2003                   Other
Pool:                                        G E Pool                             L G Pool                        Other                   (Specify)

Pool:                                         PM Pool                          CE Mgmt Pool                  Structures Pool
Pool Discipline:


Consultant:                                                              Local Government Entity:
Proj Contact Name:                                                       Project Contact Name:
Contact Title:                                                           Contact Title:
e-mail Address:                                                          e-mail Address:
Phone No:                                                                Phone No:
                                                                         Mailing Address:
                                                                         Street Address:


                                                                         City, State, Zip Code:


Contract / Modification Project Completion Date:
Contract / Modification Approval Amount ($):

Local Government
 Project Manager
   Comments:

                          Local Government Project Manager to complete red fields before submittal to Consultant Services

  I have reviewed the contract information for the project referenced above: Executive Summary, Work Plan, QC/QA Plan,
  Staffing Plan, Schedule, Insurance Certificate(s), Cost Proposal and Sub-Consultant Information (if applicable). Please
  process the contract/modificaton at your earliest opportunity.

Local Government PM Signature:


Local Government PM (Please Print Name):

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                                                                             Page 4
                             2005-2007 Pool Disciplines
1    Aerial Phtogrammetry
2    Air Quality
3    Archaeology / Enthnography / Paleontology
4    Biological / Wildlife
5    Bridge Design
6    Bridge Management / Asset Management
7    Constructability Review
8    Construction Engineering / Management
9    Dispute Resolution Review
10   Environmental / NEPA Document Preparation
11   Geotechnical / Hydrogeology
12   Hazardouse Materials / Waste Assessment and Remediation
13   Historic Architecture
14   Intelligent Transportation Systems
       Telecommunications
       Software Development / Maintenance
       Systems Management / Transportation Systems Analysis / System Engineering / Integration
       Computer or Field Hardware Installation and Testing
       Project / Systems Management
       Plan Review / Construction, Inspection and Operations
15   Landscape Architecture
16   Major Hydraulic Design
17   Materials Testing
18   Minor Structure Design
19   Noise and Vibration
20   Partnering Facilitation
21   Pavement Design
22   Planning
23   Preconstruction Engineering
24   Public Involvement / Operational / Project / NEPA
25   Research / Studies / New Development
26   Right of Way Engineering
27   RFQ/RFP Preparation / Assistance
28   Schedule Analysis and Claims Review
29   Subsurface Utility Engineering
30   Surveying / Mapping
31   Traffic Signal / Street Lighting
       Plan and Design Process
       Utilities, Structural and Geotechnical Analysis
       Construction, Inspection, Maintenance and Operations
       Documentation, "As Builts", Profiles, Geometric Design
32   Trails / Bike and Pedestrian
33   Training / Operational / Environmental
34   Value Engineering
35   Visualization / 2D / 3D / 4D
36   Wetlands
County Reference Table

 1     Beaver
 3     Box Elder
 5     Cache
 7     Carbon
 9     Daggett
11     Davis
13     Duchesne
15     Emery
17     Garfield
19     Grand
21     Iron
23     Juab
25     Kane
27     Millard
29     Morgan
31     Piute
33     Rich
35     Salt Lake
37     San Juan
39     Sanpete
41     Sevier
43     Summit
45     Tooele
47     Uintah
49     Utah
51     Wasatch
53     Washington
55     Wayne
57     Weber

				
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