PROJECT SERVICE REQUEST (PSR) FORM

Section 1: Requestor Only
Requestor:	[Insert Name]	Date:	[Insert Date]
Department/Unit:	[Insert Name of Department]
Contact Name:	[Insert Contact Name if different from Requestor]	Phone Number:	[Insert Number]
Department/Unit:	[Insert Name of Department if different from Requestor]
Dept. Approval:	[Name]	Date:	[Insert Date]
Describe the Item/Service Requested
[Description]
Describe the Goals/Objectives/Anticipated Benefits (why is this item/service needed)
[Goals/Objectives/Benefits]
Identify Stakeholders Affected by Request
[Stakeholders names]
Describe Anticipated Costs (equipment, hardware, software, etc.)
[Costs]
Constraints/Considerations (i.e., Grant Funding Cycle)
[Constraints]
Section 2: OIT Only
Date Received:	[Insert Date]
OIT Representative:	[OIT Rep. Name]
Department/Unit:	[Insert Name of Department]	Phone Number:	[Insert Number]
Request Impact Analysis
Effort (cumulative # of hours to complete request)
OIT:	[Effort Hours]	Stakeholder:	[Effort Hours]
Constraints/Considerations (i.e., Grant Funding Cycle)
[Constraints]
Integration Issues
[Insert Integration/Interface Considerations]
Financial
[Costs]
Request Reference
[ ]	OIT Strategic Plan	[ ]	Academic	[ ]	Research	[ ]	Clinical	[ ]	Administrative
[ ]	Other	[Explain]
Approval Routing
Requestor Approval:	Y	[ ]	N	[ ]	Date:	[Insert Date]
[Denial Reason]
OIT Director Approval:	[Name]	Date:	[Insert Date]
PMO Approval (if necessary):	[Name]	Date:	[Insert Date]

PROJECT SERVICE REQUEST FORM INSTRUCTIONS

The Project Service Request (PSR) document serves as the entry point for stakeholders to submit a request for OIT services. The stakeholder will specify the reason why they have submitted the request, any anticipated benefits, and estimated costs. The OIT Department will review the request and develop an impact analysis that will specify the estimated effort, duration, and financial implications. These figures are only estimates which will determine if the request is approved and if the request is designated as a project. Upon project approval, detail analysis will be performed to further define these figures.

Project Deliverable	Requirements by Project Size
Pre-Project Planning Phase	Large	Medium	Small	Requirements	Approvals
Project Service Request	R	R	O	The Project Service Request (PSR) document serves as the entry point for stakeholders to submit a request for OIT services. It is required for large scale and medium scale projects and optional for small scale projects.	The Project Service Request will have multiple levels of approvals. The first approval will be the name of the requestor’s management who has reviewed the PSR and agrees that service request should be submitted to OIT. The next approval level will begin with the IT Representative review of the PSR, including preliminary effort hours and costs, with the requestor. The requestor determines if IT should proceed further with the approval process or close the request. IT Representative then reviews the PSR with the OIT Director. The OIT Director approves the PSR or requests modifications prior to approval. The OIT Director will obtain PMO approval when PMO resources are being used to manage the project.

The stakeholder will complete the top portion of the PSR labeled ‘Section 1: Requestor Only’. After completion, the stakeholder will forward the PSR to the appropriate OIT Department for review.

Requestor completes Section 1 Requestor Only:

Requestor – The name of the individual who is requesting OIT services.

Date – The date the request was completed.

Department/Unit – The name of the requestor’s department/unit.

Dept. Approval – The name of the requestor’s management who has reviewed the PSR and agrees that service request should be submitted to OIT. Include the date the management personnel review the request.

Contact Name – The name of the individual who is initiating the service request – may be different than requestor. For example, secretary enters name as requestor, however, the contact name is the secretary’s manager.

Phone Number – The Contact’s phone number.

Department/Unit – The name of the Contact’s department/unit.

Item/Service Requested – The stakeholder will describe the type of service they are requesting from the OIT Department. Include any necessary attachments.

Goals/Objectives/Anticipated Benefits – The stakeholder will describe any anticipated benefits that will occur because of the completed service.

Stakeholders Affected by Request – The stakeholder will identify all personnel who are affected by this service request. Can include individual names, departments, etc.

Anticipated Costs – The stakeholder will identify costs associated with the service request. This can be actual known or estimated costs. Specify where costs were obtained, i.e. vendor.

Constraints/Considerations – Any additional constraints that the stakeholder may be aware of for this service request, i.e., Grant Funding Cycle.

OIT completes Section 2 OIT Only:

Date Received – The date OIT received the request.

OIT Representative – The name of the OIT personnel who is assigned to this request.

Phone Number – The OIT Representative’s phone number.

Effort – The cumulative number of hours that will take OIT and the stakeholders to complete the service request. This is an estimate based on the information provided on the service request.

Constraints/Considerations – Any additional constraints that the OIT Representative may be aware of for this service request, i.e., HL7 interface to hospital billing system.

Integration Issues – Identify any integration issues that he service request may have to address, i.e., conversion of patient database.

Financial – The estimated costs to complete the project, i.e., hardware, software, consulting, etc.

Request Reference – Designate the strategic area that the service request pertains too. If the service request does not pertain to the strategic plan or one of the governance priorities than explain in the ‘Other’ section.

Approval Routing – The service request will require several levels of approval depending on the effort necessary to complete the request.

IT Representative and Requestor Approval – IT Representative reviews the PSR, including preliminary effort hours and costs, with the requestor. The requestor determines if IT should proceed further with the approval process or close the request.

OIT Director Approval – IT Representative reviews the PSR with the OIT Director. The OIT Director approves the PSR or requests modifications prior to approval.

PMO Approval – The OIT Director will obtain PMO approval when PMO resources are being used to manage the project.

PROJECT SERVICE REQUEST (PSR) EXAMPLE

Section 1: Requestor Only
Requestor:	Mary Smith	Date:	01/04/07
Department/Unit:	Business Office – Finance
Contact Name:	John Gatteli	Phone Number:	X54293
Department/Unit:	Academic Affairs
Dept. Approval:	Thomas Kincaid	Date:	01/05/07
Describe the Item/Service Requested
Develop a database to track the number of Medicare fee schedule changes. Database needs to be accessible to the entire Business Office from every personal computer. Remote access is also desirable. Input screens need to be user friendly and developed specifically for this application. Also, reports will be required.
Describe the Goals/Objectives/Anticipated Benefits (why is this item/service needed)
Currently the tracking of Medicare fee schedules is performed on a manual basis. The approximate effort of 20 hours per week is required by a Business Office Analyst to complete this task. The effort does not take into account the numerous reports that manually have to be developed for management. Also, many times data reporting is incorrect because of the manual process. Automating this process will improve the integrity of the data, allow everyone in the department instant access to the data, and reduce the manual effort.
Identify Stakeholders Affected by Request
Entire Business Office staff – 40 employees
Describe Anticipated Costs (equipment, hardware, software, etc.)
Unknown – Don’t know the costs for a database and user licenses.
Constraints/Considerations (i.e., Grant Funding Cycle)
None
Section 2: OIT Only
Date Received:	01/06/07
IST Representative:	John Stewart
Department/Unit:	[Insert Name of Department]	Phone Number:	[Insert Number]
Request Impact Analysis
Effort (cumulative # of hours to complete request)
OIT:	120	Stakeholder:	35 – design and testing
Constraints/Considerations (i.e., Grant Funding Cycle)
None
Integration Issues
None
Duration (# of days, weeks, months, etc.)
2 months	Start Date:	02/15/07
Financial
Access Database $550, Licenses (3 concurrent $125 @), Hardware Server - $2,000
Request Reference
X	OIT Strategic Plan	[ ]	Academic	[ ]	Research	[ ]	Clinical	X	Administrative
[ ]	Other	[Explain]
Approval Routing
Requestor Approval:	Y	X	N	Date:	01/08/07
OIT Director Approval:	Sharon Clark	Date:	01/11/07
PMO Approval(if necessary):	David Gabriele	Date:	01/13/07