New TechnologyRequest Form

(Hardware and Software)

Please fill out the required information by choosing the correctitem and/or filling in the shaded areas. When completed, save the document to your home directory and print it for your files. Send the document as an attached file to your building administrator.

In addition to this completed form, please provide detailed ordering information, such as a quote from the vendor. The technology department will be responsible for ordering and testing the software once this information is received.

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PHASE I - Request(To be filled out by the Requestor and submitted to appropriate Administrator; Curriculum, Special Ed, IT, Athletic Director or Director of Assessment and School Improvement)

Requestor Name: Date Submitted:

Course & Grade Level: Date Requested By: Choose an item.

Technology Being Requested: Choose an item.

Is the item you are requesting on the MSD Standardized List: ☐ Yes ☐ No

Have you involved the IT Department: ☐ Yes ☐ NoIf yes, who:

Item Details

VendorName: Website:

Contact Info:

Description (e.g. title, version, make, model, etc.):

Qty Requested:

Intended Use/Rationale:

A software title that a person feels is valuable to their grade or department would probably be found valuable throughout the district. Please try to involve your site administrator, everyone in your level, subject area or department in your purchasing decision for a consistent use of software district wide.

Site/s: Budget Description: Account Number:

My Site Administrator has been made aware of and approves of this request: ☐ Yes ☐ No

(Site Administrator will receive a final copy of this request form)

PHASE II – Approval to Cost and/orTest(To be filled out by the appropriate Administrator and submitted to IT Secretary)

Cost will be reported back to Administrator.

Date Received: Account Number:

Signature: Date:

If disapproved, rationale:

PHASE III – Cost Analysis(To be filled out by the IT Secretary and submitted to Technology Coordinator. Attach quotes)

Date Received: Software Estimate: Hardware Estimate:

Support Costs(e.g. upgrades, maintenance, renewals, supplies etc.)

Total Year One Cost: Ongoing Yearly Cost:

Comments:

PHASE IV –Approval to Test(To be filled out by the Technology Coordinator)

Approved to Test: ☐ Yes ☐ No Signature: Date:

Comments:

PHASE V – Testing (When necessary) (To be filled out by IT Staff and/or Requestor and submitted to the IT Secretary)

Date Received:

Technology Item tested by the requestor? Choose an item.

Comments:

Signature: Date:

Technology Item tested by MSD IT Staff? Choose an item.

Comments:

Signature: Date:

PHASE VI – Approval to Purchase(To be filled out by appropriate Administrator and submitted to the IT Secretary)

Approved to Purchase: ☐ Yes ☐ No Signature: Date:

Please fill out Purchase Requisition. This request will be added to our standardized list.

PHASE VII –Final Steps(To be filled out by the IT Secretary) Date Received:

Purchase Requisition Included: Choose an item.

Copies of completed form(s) distributed to requestor and all approvers: ☐

Completed form filed in application folder: ☐ Added to Standardized List: ☐

V1.0 Revised 11/11/2013