Single/Sole Source Justification Form
Complete and submit this form
to
when requesting an exception to the competitive procurement process.
Rev. /2025 Page 1 of 3
DEFINITIONS:
Single Source: Procurements where exigent circumstances dictate use of a specific vendor due to timeliness, availability, or locality, even though other possible vendors could provide the good/service to the City.
Sole Source: Procurements where only one vendor can provide the good/service to the City.
DEPARTMENT and VENDOR INFORMATION
Requestor’s Name & Title Department & Division
Vendor Name Vendor ID Number (or write “New Vendor”)
ITEM DESCRIPTION or SCOPE OF WORK
Total Dollar Amount: $
PURCHASING EXCEPTION JUSTIFICATION
1. Why do you need to procure the requested good/service as a Single or Sole Source purchase? Select one of the following statements to justify your purchasing exception:
Sole Source:
[Uniqueness] The goods/services provided by the vendor are unique. No other vendor can provide comparable goods/services that satisfies departmental needs. [Software] The vendor provides a unique software product, which requires specialized technical capabilities that other vendors do not possess. [Systems Upgrade] Upgrade to existing system is only available from the original producer of the system who sells on a direct basis only. [Equipment Compatibility] New parts must match existing equipment or manufacturer’s technical specifications, which are only available from the same source as the original equipment.
[Repair Compatibility] Maintenance or repair services must be obtained from original manufacturer or designated servicing dealer to maintain functionality or warranty.
Single Source:
[Value] Competitive bidding is possible but will not yield value for reasons explained in the justification below.
[Circumstances] Other vendors are available, but exigent circumstances dictate use of a specific vendor due to timeliness, availability, or locality.
Single/Sole Source Justification Form
Complete and submit this form t
Rev. /2025 Page 2 of 3
2. Explain, in detail, why the proposed vendor is the ONLY vendor that meets your needs and how that relates to your response in Question 1. Why can’t this go through the competitive procurement process? Did you consider other products or services with similar capabilities? What are the consequences of NOT contracting with this vendor?
3. How was the quoted price determined to be fair and reasonable? The price compares favorably to the vendor’s previously accepted offer to the City. The price compares favorably to market prices or to previous prices found to be fair and reasonable.
The price offered to the City is equal to or lower than the price offered to another agency, company, or government. The department substantiated fair and reasonable pricing in the absence of competition, using another comparison method, explained in the justification below.
4. Based on your response above, explain the basis for comparison and include cost analyses, as applicable. Also describe any cost savings or costs avoided by acquiring the goods/services from the proposed vendor. Attach documentation for reference.
Single/Sole Source Justification Form
Complete and submit this form t
.
Rev. /2025 Page 3 of 3
5. SINGLE SOURCE ONLY: As this method is only to be used for exigent circumstances, select how these goods/services will continue after the expiration of the single source.
This is a one-time purchase that will not continue after the expiration of the single source.
This single source was requested due to a timeliness reason, and a competitive procurement will be issued to continue goods/services after the expiration of the single source.
Enter the estimated month/year you plan to issue this competitive procurement: ______________________ This single source was requested due to a value, availability, or locality reason, and another search to confirm value, availability, or locality concerns still apply will be conducted upon expiration of this single source to determine if a competitive procurement should be issued at that time.
CERTIFICATION OF RESPONSIBILITY
I am aware of the City of Riverside requirements for competitive bidding and the established criteria for justification of single/sole source purchasing. As an authorized Department representative, I have gathered the required technical information and have made a concentrated effort to review comparable/equal vendors or equipment. I hereby certify the validity of the information and feel confident this justification of single/sole source meets the City’s criteria and would withstand audit or vendor protest.
Requestor Signature Date
Department Head Signature Date
Purchasing Manager Signature Date
Note: Council must review and approve Single or Sole purchases over $100,000 after the department receives signatory approval from the Purchasing Manager. ###
08/07/2026
Riverside Medical Clinic: Occupational Medicine Program – Requested Services & Fee Proposal between
Riverside Medical Clinic – Occupational Medicine Program &
Riverside Fire Department – Annual Physicals
Mailing Address
3660 Arlington Ave.
Riverside, CA 92506
Riverside
Main Campus
7117 Brockton Ave.
(951) 782-3707
Surgery Center
7160 Brockton Ave.
(951) 782-3801
Temescal
Valley/Corona
21634 Retreat Pkwy.
(951) 493-6929
Canyon Springs/
Moreno Valley
6405 Day St.
(951) 697-5611
Eastvale
12742 Limonite Ave.
(951) 739-2746
12/11/2025
Attn: Brianna Williams
Chief Charles Tasker
Fire Department
3401 University Avenue
Riverside, CA 92501
Purpose & Scope
The purpose of this Agreement is to define pricing as it relates to services provided by Riverside Medical Clinic’s Occupational Medicine Department as requested Riverside Fire Department. Riverside Medical Clinic shall furnish the tools, equipment, materials, and labor necessary to perform services in a skillful and professional manner regarding the services described below.
Total Cost for Required Items: $665
It is Mutually Understood and Agreed by and Between the Parties That:
❖ RMC will provide Occupational Health services, providing results via email. ❖ Proposed pricing could be changed upon 60-day written notice. ❖ Payment due net 30 from date of invoice
Effective Date
❖ This proposal between RMC & Riverside Fire Department shall take effect [TBD] & will be ongoing.
Johnny Benavides
Marketing Lead, Occupational Medicine
Office: (951) 782-3029 | Email: [email protected] Riverside Medical Clinic | Universal Health Services, Inc.
REQUESTED SERVICES PRICE
1. RESPIRATOR PHYSICAL EXAM W/VITALS (REQUIRED) $85.00
2. SPIROMETRY/PFT (REQUIRED) $50.00
3. OSHA RESPIRATOR QUESTIONNAIRE (REQUIRED) $40.00
4. MMR TITER (REQUIRED) $215.00
5. VARICELLA TITER (REQUIRED) $130.00
6. HEP B TITER QUANTITATIVE (REQUIRED) $75.00
7. PPD/TB (REQUIRED) $40.00
8. INFLUENZA VACCINATION (REQUIRED – WHEN AVAILABLE) $30.00
9. CHEST X-RAY – 2 VIEW (IF NEEDED) $40.00
10. TDAP (IF NEEDED – USUALLY EVERY 10 YEARS) $50.00
11. MMR BOOSTER (IF NEEDED – PER DOSE) $110.00
12. VARICELLA BOOSTER (IF NEEDED – PER DOSE) $200.00
13. HEP B BOOSTER (IF NEEDED – PER DOSE) $80.00
COST SUMMARY
Item # Item Description UM QTY Item
Price
Total Item
Price
Item
Price
Total Item
Price
1 RESPIRATOR PHYSICAL EXAM W/VITALS 236 85 20,060.00 85.00 20,060.00 2 SPIROMETRY/PFT 236 50 11,800.00 60.00 14,160.00
3 OSHA RESPIRATOR QUESTIONNAIRE 236 40 9,440.00 40.00 9,440.00 4 MMR TITER 236 215 50,740.00 240.00 56,640.00
5 VARICELLA TITER 236 130 30,680.00 185.00 43,660.00
6 HEP B TITER QUANTITATIVE 236 75 17,700.00 160.00 37,760.00 7 PPD/TB 236 40 9,440.00 55.00 12,980.00
8 ENZA VACCINATION (WHEN AVAILABLE) 236 30 7,080.00 45.00 10,620.00 9 CHEST X-RAY – 2 VIEW 236 40 9,440.00 120.00 28,320.00 10 TDAP (EVERY 10 YEARS) 236 50 11,800.00 85.00 20,060.00 11 MMR BOOSTER (PER DOSE) 236 110 25,960.00 175.00 41,300.00 12 VARICELLA BOOSTER (PER DOSE) 236 200 47,200.00 275.00 64,900.00 13 HEP B BOOSTER (PER DOSE) 236 80 18,880.00 100.00 23,600.00 Proposed Subtotal 270,220.00 383,500.00
Agile
**City of Riverside has determined the "Winner" to be most responsive responsible bidder for highlighted stock items** Award
Notes
Riverside Medical
Clinic