UF COLLEGE OF MEDICINE

CONTRACT REQUEST FORM FOR FCPA PURCHASES

[PLEASE FILL OUT AND PRINT]

IMPORTANT – Only use this form for contract requests for FCPA purchase of goods and/or services not used in clinics. Go to the VPHA Contracts Office website for request forms for other contracts.

Please complete all questions. If question(s) are not applicable, indicate N/A on the appropriate section of this form. If the information requested is contained on the vendor’s contract document, attach their document to this form and indicate “See Attached” in the appropriate section(s) of this form.

Submit this completed form to Michael Richards, FCPA Payables, for processing. Send the completed form, along with any vendor contract documents to PO Box 103450 or hand deliver to the FCPA Payables Area 4th floor, 1329 Building. You can also email the completed form with attachments to: .

If you have questions on how to complete this form, contact Michael Richards at 352.265.8059 or via e-mail at .

  1. REQUESTING COM DEPARTMENT:

Name of COM Department: Click here to enter text.

  1. SCOPE AND PURPOSE OF PROPOSED CONTRACT:
  1. Describe the intent of the proposed contract:Click here to enter text.
  2. Briefly describe context, background and scope of services and/or obligations: Click here to enter text.
  3. Do you know if any COM department or other division already has an existing contract for this product or service with this vendor? Yes No

If yes, please list department and/or division: Click here to enter text.

  1. TYPE OF DOCUMENT REQUESTED (check one):

New Contract*: Amendment to Existing Contract**: Termination**: Renewal**:

*If new request is similar to an existing contract, attach sample document.

**Please attach a copy of the existing contract. Enter the Contract Office’s

Database number (if known): Click here to enter text.

  1. OTHER PARTY WISHING TO CONTRACT WITH COM DEPARTMENT
  1. Provide complete legal name of contracting entity (ies):Click here to enter text.
  2. Is company registered to do business in the State of Florida? Yes No

If no, what state? Click here to enter text.

  1. Name, title and mailing address of outside party representative who should receive all official notices: Click here to enter text.
  2. Name and title of legal signatory to the contract for the outside party:Click here to enter text.
  3. Identify complete address of where payments should be sent:Click here to enter text.
  4. Is there any possibility, however remote, that the outside party will have access to patient health information for non-treatment purposes? Yes No

If YES, enter the name and contact information for outside party’sHIPAA Compliance Officer:Click here to enter text.

  1. If the contract involves the use of a device or product (e.g. software, hardware), will the device or product collect or store PHI? Yes No
  2. Will the device or product (e.g. software, hardware) be connected to the network (wired or wireless): Yes No

** If answer to either IV. G or H above is yes, a security evaluation is required, Please attach the security evaluation from your IT department.

  1. COMPLETE THIS SECTION IF SERVICES ARE TO BE PROVIDED TO COM

Check here if this section is not applicable (no service is provided in contract):

  1. Provide detailed description of services and/or obligations of the other party(ies):

Click here to enter text.

  1. Is the service to be provided in UFP Clinics? Yes No

If yes, please contact Heather Hoffman and coordinate request with her; .

  1. Provide a copy of each attachment to be incorporated: Click here to enter text.
  2. Who will services be provided to (usually a COM Department or Dean’s Office Division):Click here to enter text.
  3. Amount to be paid for services? Click here to enter text.
  4. Has analysis been done to determine whether amount to be paid is fair market value? Yes No Explain process/identify methodology: Click here to enter text.
  5. Provide times/hours/frequency and location of services by the other party(ies):

Click here to enter text.

  1. Provide name (s), title(s), and FTE(s) of personnel providing services: Click here to enter text.
  2. Describe any licensure/qualification requirements or regulations: Click here to enter text.
  3. Describe equipment, space, support personnel, access, and/or other tangibles required. Include information regarding requirements to purchase tangibles and funding of maintenance cost of said tangibles: Click here to enter text.
  1. COMPLETE THIS SECTION IF PRODUCT or PROPERTY IS TO BE PURCHASED or SOLD

Check here is this section is not applicable (no sale or purchase):

  1. Describe in detail products to be purchased: Click here to enter text.
  2. Is product medical equipment or supplies to be used in UFP Clinics? Yes No

If yes, please contact Heather Hoffman and coordinate request with her;.

  1. Amount to be paid for product (Full Payment, Quarterly Payment, etc.): Click here to enter text.
  2. Per unit price: Click here to enter text. Total Price: Click here to enter text.
  3. Total # of units to be purchased? Click here to enter text.
  4. Has an analysis been done to determine whether price is fair market value? Yes No
  5. Please attach any relevant documentation.

VII.COMPLETE SECTION IF PROPERTY OR EQUIPMENT IS TO BE LEASED

Check here if this section is not applicable (no lease):

  1. Describe property to be leased. If real property, include physical address of property:

Click here to enter text.

If a lease for real property, go to section VII, Letter H.

  1. Which party is the lessee (usually FCPA)? Click here to enter text.
  2. Who will be the tenant(s)? Click here to enter text.

For each tenant, identify how the space will be used:

Click here to enter text.

  1. Has the lessor’s ownership of the property to be leased been verified? Yes No
  2. Amount to be paid for lease: Click here to enter text.
  3. Will the leased space be used exclusively by the tenant identified or will there be shared use? Click here to enter text.

If shared, please specify percentage time use by tenant:

Click here to enter text.

Identify days and times of usage. Click here to enter text.

  1. Attach documentation verifying rate is fair market value for square footage and percentage of time used.
  2. Complete Lease Summary Form and attach to this Contract Request Form.
  3. Obtain floor plan identifying portion of space to be leased and attach.
  4. If new lease, have owner provide the year built and type of construction.

VIII. CONTRACT DATES:

A. Effective date of contract: Click here to enter text.

B. Duration/term of contract if other than for an indefinite period:Click here to enter text. [Generally agreements should be for a defined period (e.g. one, two, three years), and may be subject to renewal provisions (automatic or otherwise)]

C. Do you want any renewal terms in the contact? Yes No

If yes, please explain:Click here to enter text.

OTHER IMPORTANT CONSIDERATIONS, IF ANY PERTAINING TO

THE PROPOSED CONTRACT: Click here to enter text.

WAIT!!! Before you submit your request, please respond to the following:

  • If this is a purchase or lease of equipment, please obtain and submit a quote along with this contact request. Quote attached? Yes No N/A
  • If no, please hold this contact request until all documentation is obtained.
  • If you are trading in either UF or FCPA old equipment on a new purchase, please indicate the decal number here: Click here to enter text.
  • Is a Security/IT Review needed (networked/containing PHI): Yes No N/A
  • If yes, please attach
  • Have you attached all related documentation (quotes, service contract, security/safety approvals, etc.)? Yes No N/A
  • If COM Department will be making regular monthly payment, how do you want that paid? Invoice Automatic Recurring Payment
  • Please provide any additional information that will be helpful in expediting this request:

Click here to enter text.

OPERATION APPROVAL AND CONTACT

Contact information of person providing the above information:

Name: Click here to enter text.

Telephone Number: Click here to enter text.

Email: Click here to enter text

Other: Click here to enter text.

______

Signature of Contact Person Date

______

COM Department or Division Approval Date