Exhibit 3-4 PS PRE-APPROVAL CONTROL SHEET January 1, 2015 Contract No. Base Contract or Amendment/Task Order No. The following information must be provided with every professional services base contract, amendment, task order and extra work order letter (EWOL). I. CMS INPUT INFORMATION Contract Title: (see CMS) Amendment/Task Order Title: Contract No.: Amendment/Task Order No.: Work Order No.: Dollar Value of this Action: Time Extension: days Duration: days Consultant Name: Grant No. SCOPE OF WORK: (short synopsis) PMM Manual Exhibit 3-4 2015-06-01 Page 1 Contract No. Base Contract or Amendment/Task Order No. ACTION TYPE: AMENDMENT (a - i) EXTRA WORK ORDER LETTER (EWOL) (c, d, e, i) NEW CONTRACT (a - i) CLAIM TASK ORDER (a - i) TIME (e) TRANSFER OF FUNDS AMENDMENT (a - i) ATTACHMENTS: (a) Extra Work Order Letter (EWOL (if applicable) (A&F to provide) (b) Fixed Fee Matrix (c) Independent Cost Estimate (ICE) (d) CMS Report(s): CMS-PS-008, CMS-PS-009, CMS-PS-020 (A&F to provide) (e) Consultant Cover Letter (REQUIRED) (f) Consultant Cost Proposal (Exhibit A) (g) Consultant Hour Matrices (h) Consultant Scope of Work (i) Design Change Log AUTHORIZATION LEVEL: DIRECTOR $0 - ≤ $100,000 SENIOR DIRECTOR >$100,000 - ≤ $250,000 CHIEF ENGINEER OF D&C >$100,000 - ≤$250,000 ASSISTANT GM FOR D&C >$250,000 - ≤ $500,000 GENERAL MANAGER >$500,000 - ≤$5,000,000 SECRETARY OF TRANSPORTATION >$5,000,000 - ≤$15,000,000 BOARD OF DIRECTORS >$15,000,000 ASSISTANT GM FOR D&C Time Extension PMM Manual Exhibit 3-4 2015-06-01 Page 2 Contract No. Base Contract II. or Amendment/Task Order No. ______ CONTRACT OVERVIEW 0.0% Percentage of DBE Participation this action 0.0% Percentage of DBE Commitment to date 0.0% DBE Contract Goal 0.0% Percentage of work completed Percentage is to be entered as a decimal instead of a whole #, (e.g., 10% must be entered as .10 Base contract dollar value Total authorized/pending to date, including this action III. EFFECTIVE DATE/EWOL INFORMATION This information is used to determine if the effective date of this action occurred prior to full authorization of this action. If a consultant starts work prior to the Notice to Proceed (NTP) as a result of an extra work order (EWOL), the effective date must be stated here to enable the consultant to bill for work performed prior to NTP. No work may be performed without proper authorization and no payment made for work performed prior to the effective date. There has been no prior work performed on this amendment or task order. If prior work has been performed, how did the consultant receive direction to proceed: Submission of an Extra Work Order Letter dated Executed Change Order/Amendment Verbally Email dated Effective Date of this Action: If directed verbally, please state who gave verbal direction to start this work and on what date for the following reason(s): Verbal Direction given by: Reason for EWOL: PMM Manual Exhibit 3-4 2015-06-01 Page 3 Contract No. Base Contract or Amendment/Task Order No. _____ IV. RECORD OF NEGOTIATIONS CONSULTANT ESTIMATE: $ SPECIFIC COST OR WORK ELEMENTS QUESTIONED BY THE PROJECT: (Personnel classifications for complexity of work; Hour per tasks listed in hour matrices; Duration for the scope of work; Deliverables listed in scope of work.) CONSULTANT’S RESPONSE TO MBTA’S QUESTIONS: FINAL RESOLUTION: THIS CONTRACT HAS BEEN REVIEWED WITH THE CONSULTANT, AND THE COST HAS BEEN NEGOTIATED TO $ FROM $ . If you require additional space, please attach a separate sheet. PMM Manual Exhibit 3-4 2015-06-01 Page 4 Contract No. Base Contract or Amendment/Task Order No. ______ V. FULL DISCUSSION and DBE INFORMATION MBTA Contract No. was awarded to the design firm of A Notice to Proceed was issued for the Base Contract work on BRIEF PROJECT DESCRIPTION: that has a total project budget of: (see Budget Analyst) Design Construction Real Estate Force Account Materials/Procurement Project Administration/Inspection TOTAL PROJECT BUDGET $ 0.00 The Disadvantaged Business Enterprise (DBE) participation goal on MBTA including all amendment/task orders thereto is %. Contract No. This amendment/task order contains a DBE participation of % as follows: TOTAL PMM Manual Exhibit 3-4 2015-06-01 $ 0.00 Page 5 Contract No. Base Contract or Amendment/Task Order No.______ The contract value authorized/pending to date including this amendment/task order is $ The DBE commitment to date including this amendment/task order is $ 0.00 ( %) the breakdown is as follows: Subconsultant DBE Contract Value Work Type $ 0.00 TOTAL For GM/BOD staff summary only. The DBE participation to date paid through last as of payment no. is % with the breakdown as follows: (Please print the subcontractor payment screen for all actions going to the GM/BOD for inclusion into the Staff Summary). Please use the "Contract Value (adjusted)" in CMS when calculating the paid through last %. (see attached example) DBE Contract Subconsultant Work Type Value $ $ $ $ $ $ $ $ TOTAL $ 0.00 Therefore, it is recommended that the Director approve Amendment/Task Order No. to this contract for an estimated sum not to exceed $ including a fixed fee of $ (if necessary) PMM Manual Exhibit 3-4 2015-06-01 and a contract completion date of weeks from the Notice to Proceed be approved. Page 6 AMENDMENT/TASK ORDER NO. Contract No. DESIGN CHANGE LOG # VI. DESIGN CHANGE REQUEST FORM [instructions are found in the MBTA Project Controls Policy Manual (Section VIII)] PROJECT NAME AMENDMENT/TASK ORDER TITLE CONTRACT NO. AMENDMENT/TASK ORDER NO. DESIGN CHANGE LOG # WBS # DATE EFFECTIVE DATE 1. DESCRIPTION OF PROPOSED CHANGE: 2. BASIS OF ORIGINAL DESIGN: 3. WHY WAS CHANGE NOT ANTICIPATED? 4. JUSTIFICATION OF PROPOSED CHANGE: PMM Manual Exhibit 3-4 2015-06-01 Page 7 AMENDMENT/TASK ORDER NO. Contract No. DESIGN CHANGE LOG # 5. TECHNICAL/OPERATIONS IMPACT: 6. IMPACT IF CHANGE REQUEST NOT APPROVED: 7. SCHEDULE IMPACT: a) DESIGN: (Indentify current schedule data date. List current design milestone(s) and end dates. Describe how this action will affect current design milestone(s)) b) CONSTRUCTION: (List anticipated construction advertising date and milestone. How will this action impact the anticipated advertising and milestone date?) PMM Manual Exhibit 3-4 2015-06-01 Page 8 AMENDMENT/TASK ORDER NO. Contract No. DESIGN CHANGE LOG # 8. COST IMPACT: a) DESIGN: (How will this action affect current design budget?) b) CONSTRUCTION: (How will this action affect construction budget?) DATE SUBMITTED BY: MBTA Project Manager (type name) SIGNATURE: COMMENTS: PMM Manual Exhibit 3-4 2015-06-01 Page 9 AMENDMENT/TASK ORDER NO. Contract No. DESIGN CHANGE LOG # Concur Not Concur Approved Not Approved Approved Not Approved Approved Not Approved SIGNATURE: DIRECTOR OF PROJECT CONTROLS DATE COMMENTS: SIGNATURE: AREA DIRECTOR DATE COMMENTS: SIGNATURE: CHIEF ENGINEER OF DESIGN & CONSTRUCTION (if applicable) DATE COMMENTS: SIGNATURE: AGM OF DESIGN & CONSTRUCTION (if applicable) DATE COMMENTS: PMM Manual Exhibit 3-4 2015-06-01 Page 10 CMS (example) report to be used when calculating DBE participation to date [using the Contract Value (adjusted)] the paid through last as of payment %