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Aurora Add/Change/Delete

Getting Started

Stop:   

Today's Date: 

Requester Name: 

Requester Phone: 

Requester E-Mail: 

Cost Code

AHC Organization Id: 

Area / Department Id:  

Comments: 

Materials to be Moved

       

If Other, please describe: 

Site Information
Pick Up Location

Pick Up Site Name: 

Pick Up Site Dept: 

Pick Up Site Address: 

Pick Up Suite Number: 

Pick Up City: 

Pick Up State: 

Pick Up Zip Code: 

Drop Off Location

Drop Off Site Name: 

Drop Off Site Dept: 

Drop Off Site Address: 

Drop Off Suite Number: 

Drop Off City: 

Drop Off State: 

Drop Off Zip Code: 

Pick-up Schedule

       

If Other, please describe: 

Number of service stops per day: 

Desired Start Date for scheduled pick up: 

Service Timing

Morning / Mid-Day / Afternoon / Evening: 

   

If Other, please describe: 

Pick Up Time Window

Earliest: 

Latest: 

Drop Off Time Window

Earliest: 

Latest: 

The following form will be completed by MedSpeed. Approval decision will be made by Aurora and appropriate signatures provided.

Service Timing, Solution, Cost, and Approval

Site Classification: 

REQUESTED Service Timing

Pick Up Time: 

Drop Off Time: 

Service Falls within Requested Time Windows?

Pick-up: 

Drop-off: 

Service Falls within 30 minutes of Actual Request Time?

Pick-up: 

Drop-off: 

ALTERNATIVE OPTION Service Timing

Pick Up Time: 

Drop Off Time: 

Service Falls within Requested Time Windows?

Pick-up: 

Drop-off: 

Routing Implications for REQUESTED Service
Pick Up

Stop before: 

Stop after: 

Additional Route Miles: 

Additional Drive Time: 

Additional Service Time: 

Drop Off

Stop before: 

Stop after: 

Additional Route Miles: 

Additional Drive Time: 

Additional Service Time: 

Comments: 

Routing Implications for ALTERNATIVE OPTION Service
Pick Up

Stop before: 

Stop after: 

Additional Route Miles: 

Additional Drive Time: 

Additional Service Time: 

Drop Off

Stop before: 

Stop after: 

Additional Route Miles: 

Additional Drive Time: 

Additional Service Time: 

Comments: 

Calculations
Calculations for REQUESTED Service

Add stop number: 

Transit time: 

Service time: 

Stop time: 

Stops per month: 

Total monthly time: 

Hourly Cost: 

Weekly Cost: 

Monthly Cost: 

Yearly Cost: 

Calculations for ALTERNATIVE OPTION Service

Add stop number: 

Transit time: 

Service time: 

Stop time: 

Stops per month: 

Total monthly time: 

Hourly Cost: 

Weekly Cost: 

Monthly Cost: 

Yearly Cost: 

Approval Signatures

Service Approved: 

MedSpeed Approval: 

Aurora Requestor Approval: 

Aurora Requestor's Supervisor Approval: 

(Required for final Approval) 

 

Aurora Financial Person Approval: 

Aurora Logistics Mgmt. Approval: