CONTRACT INITIALIZATION FORM
1. Contract Number: ______________ PO Number: ___________ (If Applicable)
Legal File Number: _____________ (If Applicable)
2. Contract Description Code: ___________
A: General Products
B: General Services
C: Equipment
D: Medical/Surgical/Research Products
E: Professional Services
F: Consulting Agreements
G: Temporary Employee Services (i.e., Temp Clerical, Temp Nursing, etc.)
H: Software Licenses
I: IS Equipment (i.e., PCs, Mainframe, Routers, etc.)
J: IS Services (Software Support, Programming, etc.)
K: Lease Agreements
L: Master Terms and Conditions Agreements
M: Revenue Contracts
N: Trading Partner Agreements
O: Other
P: Reagent Rental Agreement
Note: Any Contract that is coded as 00ther00shall have a detailed explanation of the coding in the description field.
3. Contract Type Code: ___________
1: Local Contract
2: Novation
3: MedAssets
4: Texas Building and Procurement
5: UT Systems
99: Other
Note: Any Contract that is coded as 00ther00shall have a detailed explanation of the coding in the description field.
4. Correctional Managed Care Contract: _____ Yes______ No
5. Contract Description: _____________________________________________________________
_______________________________________________________________________________
6. Contract Start Date: ____________________; Contract Expiration Date: _________________
Length of Initial Term: ___________ months
7. Number of Contract Renewals: __________________; Length of Renewal Term: ______ months
Renewal Prompt Date: _______________
8. Total Contract Amount (i.e., total costs for the initial term of the Contract): $_________________
9. K-Assessment : 10. Contractor: _____________________________________________________________________
Contact Person: ___________________________________Title: __________________________
Phone: _______________; Fax: _________________; e-mail: ____________________________
Address: _______________________________________________________________________
_______________________________________________________________________________
11. Requesting Department: ___________________________________________________________
Department Code: __________________________
Department Contract Manager: ______________________________________________________
Phone: ____________; Fax: ______________; e-mail: ___________________; Route: ________
12. Insurance Documents : Required: ____ Yes _____ No
(Required on all Services/Consulting/Construction Contracts)
Insurance Carrier: _________________________ Expiration Date: _______________
13. Bond Documents: Required: ____ Yes _____ No
(Required on all Construction Contracts)
Bonding Company: ________________________ Expiration Date: _______________
14. HUB Subcontracting Plan (HSP): _____
A = Contractor is Subcontracting
B = Contractor is not Subcontracting
C = HSP was not required.
15. GPO Contract: _____ Yes______ No GPO # Exp.
GPO: ___________________ Commitment Letter Required: _____ Yes _____ No
16. Rebate Offered?: _____ Yes______ No Rebate Amount: ______________ Rebate Date: _______________
17. 00ontract Activity File00 Required? _____ Yes______ No
18. Contract Prompt Date: __________________________
19. Will Contract be Managed by Department? _____ Yes______ No
20. Will Contract Administration Review all Payments? _____ Yes______ No
21. Audit Date: ___________ Audit Frequency: Monthly, Quarterly, Semiannually, Annually
Initial Audit Date: _______________________
22. Should this Contract be included in any internal or external reports? Yes ____; No _____
23. Clinical Operations Contract? Yes ____; No _____
24. PO00 processed by Clinical Purchasing Team? Yes ____; No _____
25. Will Contractor have employees on-site (i.e., at UTMB)? Yes ____; No _____
Completed By: ______________________________________ Date: ________________
Approved By: _____________________________________ Date: ________________
Kyle Barton
Contracts Manager
Revision 1.1; 7/21/05
