REV 10/19/2021 Page 1 of 3 PROCUREMENT JUSTIFICATION FORM (PJF) This form must accompany all contract requests and sole source requisitions (RQS) over $5,000 submitted to the Division of Procurement Services. INSTRUCTIONS: Please provide the requested information in the white spaces below. All responses (except signatures) must be typed; no hand-written forms will be accepted. See the guidance document posted with this form on the Division of Procurement Services intranet site (Forms page) for additional instructions. PART I: OVERVIEW Department Office/Division/Program: DHHS/OFI/DDS Department Contract Administrator or Grant Coordinator: Shawn Belanger / Brianne Carrero (If applicable) Department Reference #: Multiple, See attachment Amount: (Contract/Amendment/Grant) $ 3,669,516.00 Advantage CT / RQS #: Multiple, See attachment CONTRACT Proposed Start Date: 10/1/2022 Proposed End Date: 9/30/2024 AMENDMENT Original Start Date: Effective Date: Previous End Date: New End Date: GRANT
Project Start Date: Grant Start Date: Project End Date: Grant End Date: Vendor/Provider/Grantee Name, City, State: Multiple, See attachment Brief Description of Goods/Services/Grant: Medical and Psychological Services PART II: JUSTIFICATION FOR VENDOR SELECTION Mark an X before the justification(s) that applies to this request. (Check all that apply.) A. Competitive Process G. Grant B. Amendment H. State Statute/Agency Directed C. Single Source/Unique Vendor I. Federal Agency Directed D. Proprietary/Copyright/Patents J. Willing and Qualified E. Emergency K. Client Choice F. University Cooperative Project L. Other Authorization DocuSign Envelope ID: 1025343A-CDBF-414C-BCF5-D43091985255 DEPARTMENT OF ADMINISTRATIVE AND FINANCIAL SERVICES a) DIVISION OF PROCUREMENT SERVICES SU Wu Le) BAUS} DocuSign Envelope ID: 1025343A-CDBF-414C-BCF5-D43091985255 David Morris 9/21/2022 DocuSigned by: 2A644AF5681F 482... Procurement Justification Form (PJF) REV 10/21/2021 Page 3 of 3 Office: OFI Service Group: Medical and Psychological Consulting Services No. of Vendors: 17 Service Group Total: 3,669,516.00 Agreement Number Vendor Month @ Rate Rate Projected Monthly Units Authorized Monthly Units Projected Amounts 1 DDS-23-005 James H Hall 24 $85.00 104.00 164.00 $ 212,160.00 2 DDS-23-007 Archibald Hobbs Green 24 $73.00 123.00 183.00 $ 215,496.00 3 DDS-23-008 David R Houston, PhD 24 $75.00 150.00 210.00 $ 270,000.00 4 DDS-22-009 Karyn Diamond, MD 21 $70.00 180.00 240.00 $ 264,600.00 DDS-22-009 Karyn Diamond, MD 3 $73.00 180.00 240.00 $ 39,420.00 5 DDS-23-010 Thomas A Knox PhD 24 $85.00 120.00 180.00 $ 244,800.00 6 DDS-23-011 Mary Alyce Burkhart, PhD 24 $75.00 130.00 190.00 $ 234,000.00 7 DDS-23-012 Lewis F Lester, PhD 24 $75.00 108.00 168.00 $ 194,400.00 8 DDS-23-014 Sharon Hogan 24 $73.00 100.00 160.00 $ 175,200.00 9 DDS-23-017 Donald Trumbull, MD 24 $75.00 130.00 190.00 $ 234,000.00 10 DDS-23-018 Stephanie L Haskell, PhD 24 $75.00 139.00 199.00 $ 250,200.00 11 DDS-23-019 Brian N Stahl, PhD 24 $75.00 122.00 182.00 $ 219,600.00 12 DDS-23-020 Robert L Maierhofer, PhD 24 $75.00 56.00 116.00 $ 100,800.00 13 DDS-23-022 Ben Weinberg, MD 24 $75.00 173.00 233.00 $ 311,400.00 14 DDS-23-026 Edward R Ringel 24 $73.00 100.00 160.00 $ 175,200.00 15 DDS-23-030 Melanie Thompson, MD 24 $70.00 91.00 151.00 $ 152,880.00 16 DDS-23-032 Barda Leavitt 24 $68.00 90.00 150.00 $ 146,880.00 17 DDS-23-033 Christopher Bartlett 24 $68.00 140.00 200.00 $ 228,480.00 $ 3,669,516.00 DocuSign Envelope ID: 1025343A-CDBF-414C-BCF5-D43091985255