University of Kentucky Healthcare Enterprise
* required fields Recommendation Evaluation Worksheet (REW)
Request date 3/21/2018
Requestor's name * (Phone ext.) *
Entities involved

(Intended for)

Budgetary Impact
UK Entity Department Name Cost Center Number

Potential other users/services
Describe the current product/service *
Describe the proposed action/opportunity/product or service including catalog numbers *
(Or check applicable boxes below)
Types of opportunities * (Check all applicable)

- Attach labor impact form!
Stock preference *

CPT/ICD-9 code(s) & description *
Annual volume estimates *
Product(s) it replaces for this procedure? (include SAP #) *
Recommended suppliers
Sales rep name
(Home phone)
(Cell phone)
Does product/service require review by
Attach files to this request?