N95 Respirator Masks

REV 10/19/2021 Page 1 of 2 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 Riverview Psychiatric Center Department Contract Administrator or Grant Coordinator: Shawn Belanger (If applicable) Department Reference #: RPC-22-603 Amount: (Contract/Amendment/Grant) $27,796.62 Advantage CT / RQS #: RQS 10A 20211109000000000527 CONTRACT Proposed Start Date: 11/5/2021 Proposed End Date: 06/30/2022 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: 3M Co. St. Paul, MN Brief Description of Goods/Services/Grant: N95 Respirator Masks 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 X C. Single Source/Unique Vendor I. Federal Agency Directed D. Proprietary/Copyright/Patents J. Willing and Qualified X E. Emergency K. Client Choice F. University Cooperative Project L. Other Authorization DEPARTMENT OF ADMINISTRATIVE AND FINANCIAL SERVICES a) DIVISION OF PROCUREMENT SERVICES SU Wu Le) BAUS} Justin Franzose 11/19/2021 DocuSigned by: Quatin Sranypoe AEED9C7B3A8044E... Procurement Justification Form (PJF) Please respond to ALL of the questions in the following sections. PART lll: SUPPLEMENTAL INFORMATION 4.-- Provide a more detailed description:and explain the need for the: goods, services or:grant to supplement the response in Part I. The Department's Riverview Psychiatric Center (RPC) is purchasing N95 respirator masks as part of its response fo the Covid-19 pandemic and in preparation for facility outbreak. 2. Provide.a brief justification for the selected vendor to supplement the response. in. Part |: Reference the RFP. number, if applicable: This vendor is able to provide RPC with a large supply of N95 respirator masks. This is an emergency purchase, only one other quote was obtained by RPC and was significantly higher. 3. Explain -how the negotiated costs or rates are fair-and.reasonable; or how.the.funding was allocated to grantee: The cost of this purchase has been pre-negotiated between the Department and vendor and has been determined to be fair and reasonable. 4..-Describe the plan-for future-competition-for the goods orservices. The Department does not intend to competitively procure these items. This is a one-time emergency purchase. PART. IV: AMERICAN. RESCUE PLAN. ACT (ARPA) / MAINE JOBS. & RECOVERY. PLAN (MJRP) Does this request utilize ARPA/MJRP. funds? Yes If Yes, please attach the approved Business Case(s). X No If No, proceed to Part VI ; PART.V: APPROVALS : Depa fooete boniniecnor By signing below, I signity that | approve of this procurement request. Eee designee): Printed Name: bu Mnwn Date: | //7/2| Signature of DAFS Procurement Official: Printed-Name: Date: REV 10/19/2021 Page 2 of 2