CMS–400, Printing Services Requisition Form

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CMS–400, Printing Services Requisition Form

DEPARTMENT OF HEALTH & HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

CMS PRINTING SERVICES REQUISITION

1. REQUISITION NUMBER 2. DATE OF REQUISITION

I. SERVICES REQUESTED (to be completed by originating office)

3. ORDERING ORGANIZATION 4. PERSON TO CONTACT / LOCATION AND EXTENSION

WRAP BAND

5. FINISHED PRODUCT DESIRED

6. QUANTITY

BOOKS OR

❏ PAMPHLETS ❏ BLANK

FORMS ❏ FOLDERS ❏ SNAPOUT

SETS ❏ CONTINUOUS

FORMS ❏ OTHER

(SPECIFY)

❏ SHRINK

WRAP ❏ BOX ❏ CARTON ❏ PACKAGE

7. SERVICE REQUESTED

8. TYPE OF REQUEST

9. PREVIOUS REQ. NO.

❏ PRINTING ❏ DUPLICATING ❏ OTHER

❏ NEW

(SPECIFY)

MATERIAL ❏ REPRINT ❏ REVISION

10. FORM OR PUBLICATION NUMBER 11. NO. OF 12. TITLE OR DESCRIPTION OF MATERIAL 13. DESIRED

AND REVISION DATE

TEXT PAGES

DELIVERY DATE

14. DISPOSITION INSTRUCTIONS FOR OLD STOCK, IF MATERIAL REVISED 15. CENTER / OFFICE APPROVAL 16. DATE

ISSUE OLD STOCK ISSUE OLD STOCK

❏ UNTIL EXHAUSTED ❏ UNTIL___________ ❏ DESTROY

OLD STOCK

II. DELIVERY INSTRUCTIONS (to be obtained by originating office)

17. WHERE TO SHIP FINISHED PRODUCT (ENTER QUANTITY TO EACH POINT)

18. LABELS/SHIPLIST 19. DISTRIBUTION CODE(S)

CMS WHSE

INV. CTRL. NO UNIT OF ISSUE OTHER

❏ ATTACHED #_______

III. REQUIRED CLEARANCES (to be obtained by originating office)

20. CENTER / OFFICE BUDGET APPROVAL

21. COST ESTIMATE

APPROPRIATION NO. COMMON ACCOUNTING NO. FUNDS AVAILABLE (SIGNATURE OF BUDGET OFFICE) PRINTING (INITIALS & DATE)

22. CMS-OMB APPROVAL

23. PUBLIC USE APPROVAL

POSTAGE (INITIALS & DATE)

NUMBER & EXPIRATION DATE

❏ 615 ATTACHED

❏ OEA SIGNATURE & DATE___________________________

IV. JOB CONTROL INFORMATION (to be completed by DPMS)

24. DATE CMS-400 RECEIVED 25. GPO REQUISITION NO. / PROGRAM NO. 26. FORMS / PUBLICATIONS APPROVAL 27. PRINTING / PROCUREMENT APPROVAL

(INITIALS & DATE)

FOR ACCOUNTING (INITIALS & DATE)

V. SPECIFICATIONS FOR PRINTING AND COMPOSITION (to be completed by DPMS, if CMS Publication)

28. SIZE FLAT

SIZE FINISHED 29. MARGINS (FRONT) 30. MARGINS (BACK) 31. PAGE PROOFS 32. PRINTER’S PROOFS REQUESTED

(INCHES)

PRODUCT (INCHES)

NO. HOLD

WIDTH LENGTH WIDTH LENGTH LEFT TOP RIGHT TOP SETS DAYS ❏ BLUELINE

X

X

❏ MATCH PRINT

❏ OTHER

(SPECIFY)

33. NAME, ADDRESS, EXTENSION TO SEND PROOFS

❏ DIGITAL PROOF

34. SUBMITTED FOR PRINT 35. PAPER (WHITE 20LB USED UNLESS SPECIFIED)

36. TYPE

37. PRINT

38. SETS MUST

TEXT & RULE ILLUSTRATIONS COLOR KIND WEIGHT INK

OF COVER

REGISTER

❏ ONE SIDE ONLY

❏ CAMERA COPY ❏ HALF TONE

❏ SELF

❏ YES

ART

❏ HEAD TO HEAD

❏ DISK / CD

❏ LINE ART

❏ SEPARATE ❏ HEAD TO FOOT ❏ NO

❏ NEGATIVES

❏ ❏ HEAD TO SIDE

❏ MANUSCRIPT ____________

39. BINDERY OPERATIONS

COMB BIND

INCHES FROM TOP INCHES FROM LEFT

PERFECT BIND

PASTE ON FOLD

STITCH ULC

SPIRAL BIND

}

❏ SADDLE STITCH(ES) ❏ LOOSELEAF ❏

40. DRILLING (PUNCHING) ___ ❏ GATHER IN SETS ❏ PERFORATE

IN. CENTER TO CENTER 41. PADDING BACKBOARD ___ SHEETS IN PAD 42. RETURN COPY TO

___ ROUND HOLES ___ IN. FROM SIDE

___ SHEETS IN SET

___ IN. DIAMETER ___ IN. FROM TOP ❏ ___ ❏ SIDE ❏ YES

SETS IN PAD ❏ DESTROY

CMS

43. INTERNAL PACKAGING

❏ ❏

IN QUANTITIES OF 44. EXTERNAL PACKAGING

IN QUANTITIES OF

45. SPECIAL INSTRUCTIONS

❏ ADDITIONAL INSTRUCTIONS ON ATTACHED SHEET

Form CMS-400 (01/05) EF 01/2005

COPIES TO: PRINT FILE • DPMS TRACKING • FORMS • WAREHOUSE • ACCOUNTING • CUSTOMER


FORM CMS-400 PRINTING SERVICES INSTRUCTIONS

SECTION I

ITEM 1. REQUISITION NUMBER: Enter the complete 4-part requisition number.

You Center/Office Budget Officer should give the requisition number in accordance

with this procedure. Components will use an alphanumeric numbering system.

ITEM 2. DATE OF REQUISITION: Enter the month, day, and year that the

requisition number is assigned.

ITEM 3. ORDERING ORGANIZATION: Enter the acronym of your

Center/Office/Division.

ITEM 4. PERSON TO CONTACT/LOCATION AND EXTENSION:

Enter the name of the Contact Person who will be able to answer any questions

about the requested print along with the room/bay location, and telephone number.

ITEM 5. FINISHED PRODUCT DESIRED: Check the applicable box to indicate

the finished product desired. If “Other” is checked, use the space provided to explain

the type of product. If additional space is needed use Item 45, Special Instructions.

ITEM 6. QUANTITY: Enter the number of items of the finished product to be

printed (pamphlets, books, pads, blank forms, etc.).

ITEM 7. SERVICE REQUESTED: Check all applicable boxes.

Printing: Check when printing of any form or publication is required.

Duplicating: Check when duplication (photocopying) of any form or publication

is required.

Other (Specify): Check when the service requested is for other than printing or

duplicating. Be sure to specify the service requested in the space provided. If

additional space is needed use additional instructions in Item 45.

ITEM 8. TYPE OF REQUEST: Check the appropriate box.

New Material: Check when the material to be printed is new material that

has not previously been produced.

Reprint: Check when previously printed material again needs to be reproduced.

Attach two samples. Please provide in Item 9 the previous Requisition Number.

Revision: Check when existing material to be printed is changed in form or

substance from the previous printing. Please provide in Item 9 the Previous

Requisition Number.

ITEM 9. PREVIOUS REQUISITION NUMBER: Fill in the Previous

Requisition Number when available. If in Item 8 you checked “Reprint” or

“Revision” you should also fill in this block with the Previous Requisition Number

which can be found on the previous Form CMS-400 in Item 1.

ITEM 10. FORM OR PUBLICATION NUMBER AND REVISION DATE:

Enter the form number or publication number, and the revision date of the revision

to be printed.

ITEM 11. NO. OF TEXT PAGES: Enter the total number of pages in the form

or manuscript being submitted with the CMS-400. Covers and blank pages are

counted as pages.

ITEM 12. TITLE OR DESCRIPTION OF MATERIAL: Enter the title exactly

as it should appear on the material ordered. If the title is being revised from a previous

printing, enter the revised title.

ITEM 13. DESIRED DELIVERY DATE: Enter the date by which the material

should be received by the requesting or using office. Do not use ASAP, but specify a

definite date. If the desired delivery date cannot be met, DPMS will call the Contact

Person to discuss alternatives. Please note an appropriate time frame is 5 weeks from

the date DPMS receives a completed CMS-400 with all appropriate materials.

ITEM 14. DISPOSITION INSTRUCTION FOR OLD STOCK,

IF MATERIAL REVISED: Check the appropriate box.

Issue Old Stock Until Exhausted: Check if present version of form or

publication should continue in use after the new material has been published,

until the old stock has been depleted.

Issue Old Stock Until: Specify a date; e.g., if the new publication has an

effective date before which its release is not authorized, or other time, e.g., “until

new material available.” If new material is superseding or obsolescing one or several

forms or publications, Item 45, Special Instructions, must be used to identify the

obsolete or superseded material. Give any additional disposition instructions for

existing stock.

Destroy Old Stock: Check if current stock needs to be destroyed.

ITEM 15. CENTER/OFFICE APPROVAL: This is for your Center/Office,

if he or she has been designated the authority to approve the Printing Services

Requisition. The signature indicates that the CMS-400 and attachments have been

reviewed, that the package is complete and ready for forwarding to the appropriate

Budget Officer for Funds Available.

ITEM 16. DATE: Enter the date Item 15 was signed.

SECTION II

ITEM 17. WHERE TO SHIP FINISHED PRODUCT

(Enter Quantity to Each Point)

CMS Warehouse: Indicate the number of copies to be stored in the CMS

Warehouse facility.

Inventory Control Number: The requesting Office must call The Division of

Property & Space Management Services (x 67849) to obtain an inventory control

number (ICN) for any material to be warehoused. Form ICN’s may be obtained by

contacting the Divison of Publications Management Services (ext.67898). Enter the

ICN in this block.

Unit of Issue: State the unit of issue in terms of the finished product and packaging.

For example, if pads are being ordered and are to be issued from the warehouse in

packages of 10 pads to a package, enter 10 as the unit of issue and be certain that

Item 43, Internal Packaging indicates preparation of the material in quantities of 10.

Other: Indicate here and in Item 45 (if additional space is necessary) any special

delivery instructions not otherwise covered by specific items on the CMS-400.

ITEM 18. LABELS/SHIPLIST: Please check the box if you have any labels or

shipping list attached and enter the number of addresses in the space provided that

the materials will be shipped to.

ITEM 19. DISTRIBUTION CODES: If DPMS maintains the mailing list and

supplies the labels, enter here the code or code to be used for initial distribution of

the finished product.

SECTION III

ITEM 20. CENTER/OFFICE BUDGET APPROVAL:

Appropriation Number: Enter the correct fiscal year appropriation number;

make certain that it corresponds to Item 1, Requisition Number.

Common Accounting Number: Enter the Common Accounting Number

(CAN) of the entity that will pay for the requested services.

Funds Available (Signature of Budget Office): The requesting B/O budget

officer or other individual designated in writing to certify funds availability, must

sign and date this block.

ITEM 21. COST ESTIMATE:

Printing (Initials/Date): DPMS Printing Specialists will estimate the total printing

cost of the services requested on the CMS-400. DPMS Printing Specialist must

initial and date the cost estimate provided.

Postage (Initials/Date): DPMS Mail Management Specialists will estimate the

total postage/distribution cost of the services requested on the CMS-400. DPMS

Mail Management Specialist must initial and date the cost estimate provided.

ITEM 22. CMS-OMB APPROVAL NUMBER & EXPIRATION DATE

CMS will not arrange to print any OMB approved documents that have expired.

ITEM 23. PUBLIC USE APPROVAL

The CMS Office of External Affairs (OEA) must approve all Publications prior to

DPMS receiving the CMS 400.

SECTION IV – TO BE COMPLETED BY DPMS/ACCOUNTING

ITEM 24. DATE CMS-400 RECEIVED

This block will indicate the date your completed materials, ready for printing are

received by DPMS.

ITEM 25. GPO/REQUISITION NUMBER/ PROGRAM NUMBER

This block will indicate the Government Printing Office (GPO) Requisition and/or

Program Number, which will be issued by the DPMS Printing Specialist.

ITEM 26. FORMS/ PUBLICATION APPROVAL (INITIALS & DATE)

This block will be indicate the Form or Publication has been reviewed by the Forms

Officer and/or person(s) responsible for Publications. The Initials and Date signifies

the form or publication is OK for printing.

ITEM 27. PRINTING/PROCUREMENT APPROVAL FOR ACCOUNTING

(INITIALS & DATE)

This block is for Accounting to Initial and Date that funds have been certified.

SECTION V – SPECIFICATIONS

Will be completed by DPMS after conferring with Contact Person listed in Item 4.

Form CMS-400 Instructions

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