Institution Name
Select University
Alcorn State University
Delta State University
Jackson State University
Mississippi State University
Mississippi University for Women
Mississippi Valley State University
University of Mississippi
University of Miss. Medical Center
University of Southern Mississippi
Submission Date 2/4/2012
Agenda Date
Select Month
January
February
March
April
May
June
July
August
September
October
November
December
Select Year
2009
2010
2011
2012
2013
2014
Contractor Name
Type of Contract
Select One
Expenditure
Revenue
Select One
New
Renewal
Modification
Start Date of Contract
End Date of Contract
Purpose of Contract
Select One
Consulting/Professional Services
Lease
Marketing/Advertising
Outsourcing
Private Audit
Technology
Other (explain)
Additional Explanation Related to Purpose of Contract
Has contract been approved by MS Information for Technology Services (ITS)? Copy of ITS approval must be submitted with other documentation.
Select One
Yes
No
Not Applicable
Does contract comply with State law and purchasing procedures?
Select One
Yes
No
Not Applicable
Complete either Section A. or B. below based on Contract Type
A. Expenditure Contract
Total Expenditure Contract Amount
$
Cost of Contract by Fiscal Year
FY
FY
FY
FY
FY
Budget unit from which contract will be funded?
Were funds for this contract included in the original budget?
Select One
Yes
No
If the total contract amount is $5 million dollars or greater, has the Institution’s Executive Officer discussed the contract with the Commissioner of Higher Education?
Select One
Yes
No
B. Revenue Contract
Expected Revenue over period of contract
$
If a new contract, how was objective previously met?
Explain Contractor Selection Process
Select One
RFP
RFQ
Bid
Other (explain)
Is Contractor a Certified Historically Underutilized Business (HUB)?
Select One
Yes
No
Dollar Value of work being subcontracted to HUB?
$
Explain cost/benefit analysis method used to determine the cost-effectiveness of hiring outside workers versus utilizing in-house employees or hiring additional employees.
Is a written explanation on file addressing how this contract fits into the department’s mission, goals, and objectives?
Select One
Yes
No
Does the contract expressly stipulate that the contractor is an independent contractor and not an employee of the MS IHL?
Select One
Yes
No
Does the contract describe the scope of work and provide that payments are made after services are rendered?
Select One
Yes
No
Does the contract stipulate the standard or level of performance the contractor is required to meet?
Select One
Yes
No
Has it been confirmed there are no significant risks related to this contract?
Select One
Yes
No
Provide a list of all persons and entities which are financially interested in the contract. In addition, with respect to each entity that is financially interested in the contract, provide a statement identifying any entity that directly or indirectly owns 10% or more of the outstanding ownership interest in the identified entity, or provide a statement that that there are no such entities.
Provide this same information/certification as to any parent corporations or entities of the identified entity financially interested in the contract.
Is the contract complete, with all pages, exhibits, schedules, etc. incorporated within the terms of the contract and attached?
Select One
Yes
No
Has the HUB Contractor List (identifies all HUB contractors who bid on this project) been completed and attached?
Select One
Yes
No
Was YES or NO checked for every question on this document?
Select One
Yes
No
If NO was selected for any question, please explain why.
Institution's Contact Name
Official Job Title
Email Address
Phone Number
Institution's Chief Financial Officer
University Medical Center CFO (if applicable)
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