Name of Vendor Submitting Alternate Approval
(Required)
Title
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Phone
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Email
(Required)
Name of Product/Technology/Service
(Required)
Is this a:
(Required)
Product
Technology
Service
(please select all that apply)
Product Type(s), Style(s) or Model(s):
(Required)
Name of Product/Technology Manufacturer or Service Provider:
(Required)
Manufacturer Contact & Title:
(Required)
Manufacturers’ full address:
(Required)
Description of Product/Technology/Service:
(Required)
This includes the brand name, product code, product description, grade, color, size (dimension) and weight (if applicable) and MSRP price.
Describe in detail why this does not fall within the current specifications for FAC118.
(Required)
These specifications may be found linked in the 'Review FAC118 Specifications Before Submitting' section or in the FAC118 MBPO in COMMBUYS by navigating to ‘Additional Attachments’ and viewing Attachment A: Mandatory Specifications and Desirable Criteria of the RFR.
Is this request for an On-Site Generation Unit of Disinfectants and Sanitizers? If so, please see requirements below.
(Required)
Yes
No
Please provide the following documentation along with this application:
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1. Marketing Materials for Product (please attach electronically or provide a link) 2. SDS for product (if applicable) 3.EPA Registration Number or an EPA Establishment Number (if applicable) 4. Performance Testing Data that has been completed by a 3rd party.
For On-Site Generation Unit of Disinfectants and Sanitizers, must also include:
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1. For hypochlorous acid generators, must include independent documentation of the pH of the solution over time to prove it maintains a pH of 4-6.5. 2. For other disinfectant generation units must disclose the efficacy the equipment provides and include independent documentation. This includes but is not limited to the manufacture’s technical data sheet, the safety data sheet (SDS) for the raw materials and the end product, and efficacy information against bacteria, virus and fungi. 3. Confirmation that all devices meet Federal, State and Local requirements for their use.