(NOTE: You must tab through fields)

Dean’s or Divisional Office submit to purch@bussvc.wisc.edu REQ# _________________

CONTRACT DETAILS

This agreement is entered into between the Board of Regents of the University of Wisconsin System on behalf of the University of Wisconsin-Madison Department of (insert Department/School Name): __________________________ (hereafter University) and (insert Contractor’s Name): __________________________________________________

(hereafter Contractor):

CONTRACTOR INFORMATION (NAME/ADDRESS)

Contractor’s Name (as shown on W9): ___________________________________________

Address: ____________________________________________________________________

City / State / Zip: ______________________________________________________________

Contact Name / E-Mail: _________________________________________________________

CONTRACT TERM (length of agreement) (NOTE: Requisitions with beginning and ending dates cannot exceed a one-year period. If the contract term is > one year, multiple requisitions may be needed).

Start Date: ______________________	End Date: ______________________

COMPENSATION INFORMATION

Fee not to exceed (total amount to be paid for the full contract term)	$ ______________________

Expenses not to exceed (if expenses are not included in the fee)	$ ______________________

List expenses to be paid: _____________________________________________________________

(Check √ all that apply)

☐ Paid on Purchase Order	OR	☐ Separately (e.g., PIR)

☐ Limited to State reimbursement levels	☐ Receipts required

PAYMENT TERMS: (NOTE: Payment will be made 30 days upon receipt of an invoice from the Contractor. Contractor must invoice according to the terms of the contract.)

How often should Contractor invoice? (e.g., monthly, quarterly, by milestone) ______________________

Rate and payment details: __________________________________________________________________

DEPARTMENT CONTACT INFORMATION (Department contact responsible for monitoring deliverables)

Name:	__________________________________________________________________

Telephone:	__________________________________________________________________

E-mail:	__________________________________________________________________

PROJECT SCOPE (Brief description of services to be provided by Contractor.)

Scope of Service: __________________________________________________________________________

PROJECT DELIVERABLES

Deliverables – include the following:

Detailed measureable work product (i.e. data, designs, drawings, reports, etc. that will be produced)

Timeline of major deliverable due dates

Milestones tied to payments so the work can be monitored.

Course name, dates, if applicable.

Final report, if required

____________________________________________________________________________________

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____________________________________________________________________________________

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ADDITIONAL CONTRACT DETAILS (check √ all that apply)

☐ HIPAA – Service provider will create, receive, transmit or store Protected Health Information (PHI).

If yes, please contact your school’s HIPAA security officer or the UW-Madison HIPAA privacy officer for additional contracting requirements (https://compliance.wisc.edu/hipaa/coordinators).

☐ Yes ☐ No

☐ FERPA – Service provider will have access to UW student information.

☐ Yes ☐ No

☐ IP – There are intellectual property issues associated with this service (See Schedule A http://www.bussvc.wisc.edu/purch/forms/ScheduleAforASSAsolesourcejust.doc).

☐ Yes ☐ No

☐ Risk Management

☐ Yes ☐ No	Will the service provider be performing work on campus?

☐ Yes ☐ No	Will the service provider be in direct contact with minors?

☐ Yes ☐ No	Are the services high risk in nature (e.g. medical services, equipment	maintenance, travel services, etc.)?

Additional Information (if applicable):

______________________________________________________________

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