Justification For Acquisition And Use Of An Office Printer Request Form

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Justification for Acquisition and Use of an Office Printer
Request Form
USER INFORMATION
Name:
Position Title & Grade:
Bldg/Room #:
Department/Branch or Section:
Office Phone Number:
Current printer location (Applicable):
PRINTER INFORMATION (complete the justification area below if the printer will not be used by 3
or more users)
Request Workgroup Printer
Request Single Office Printer
Replacement
If Replacement please provide
Medium Volume B&W Laser Duplex Printer (HP P3015DN) $ 725
Decal
High Volume B&W Laser Duplex Printer (HP M602DN) $ 1,165
Number:______________
Medium Volume Color Laser Duplex (HP M451DN) $ 365
High Volume Color Laser Duplex (HP CP4525DN) $ 1385
CAN__________________
MFP B&W Duplex Copier, scanner, fax, and printer (HP 1536DNF) $ 269
MFP Color Duplex Copier, scanner, fax, and printer (HP M276NW) $ 335
Note:
Replacement Black and White Printers that have reached useful life and are not cost effective to repair are replaced at
no charge. New printers or replacement color printers are charged to the department CAN.
JUSTIFICATION:
I am submitting this request because my job responsibilities require me to (check all that
apply):
Print sensitive, PII, or PHI documents on a regular basis documents should not be seen by all users
Print documents related to the supervision or counseling of staff
Based on my location there are no other printers within a reasonable walking distance
Reasonable Accommodation based on a documented request
Other: (Please enter reason below):
SIGNATURES
__________________________________
___________________
Signature
Date:
__________________________________
___________________
Immediate Supervisor
Date
__________________________________
___________________
Department Head
Date:
DECISION
Approved
Disapproved
Comments:
_________________________
_____________________
Chief Information Officer
Date
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