Prospective Supplier Survey

1. UNITED IROQUOIS SHARED SERVICES

Group Purchasing Program -Prospective Supplier Survey

We are pleased that you are interested in researching the possibility of becoming a local contracted supplier with UISS. UISS currently represents over 900 health care purchasing locations within our geographical region. We strive to provide high quality products to our members at the lowest possible price.

In order to be eligible to contract with UISS, a vendor must be an entity that is duly formed and in good standing under the laws of the relevant jurisdiction and, to the extent applicable, licensed to provide the products and services for which it seeks to submit a proposal. UISS reserves the right to disqualify any vendor based on objective evidence of possible violation of the law or failure to comply with industry standards. UISS encourages the participation of small, women, and/or minority-owned businesses. Eligible vendors must meet all applicable Joint Commission on on Accreditation of Healthcare Organizations (JCAHO), regulations and must not be on the Medicare exclusion list.

UISS is affiliated with Acurity and Premier / Innovatix. Our local program portfolio is designed to supplement the contracting portfolio available on the regional (Acurity) and national (Premier / Innovatix) level.

Please complete the Prospective Supplier Survey and hit submit. A copy will be sent to Mike Bevivino, Director of Supply Chain Strategies. All information will be maintained as proprietary and confidential.

Question Title

1. Please provide your Company Information.

Name: *

Company: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Country:

Email Address: *

Phone Number: *

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2. Address

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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3. Have you used any previous name or DBA in the last 5 years?

Yes

If so, name?

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4. Do you currently have any pending liens? Are you currently excluded from doing business with federal, state, or city government agencies?

Yes

If Yes, explain.

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5. Please provide your company web site address.

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6. Provide a brief description of your product/service.

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7. Who within a UISS facility would be primarily responsible for purchasing your product/service?

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8. What is the average dollar amount spent on your product/service? Is this calculated on a dollar per bed or per procedure basis, identify how this is calculated?

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9. Number of full-time employees?

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10. Hours of Operation?

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11. Describe customer service capabilities.

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12. How are orders placed by customer?

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13. How are products delivered to customer, who is responsible for freight charges?

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14. Preferred payment terms are Net 60 Days, describe in detail your payment terms.

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15. Who are your actual/potential competitors?

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16. Are there any member classification restrictions?

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17. Are there any geographical restrictions within the Upstate New York region?

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18. What percentage of marketshare do you currently enjoy in Upstate New York region?

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19. Is your company currently affiliated with any GPO? Please identify.

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20. Describe any value added services your company provides.

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21. What potential benefits does your company/product /service offer?

Please remember to email Mike Bevivino at mbevivino@iroquois.org to notify him of your survey submission.