ࡱ> wzv ^!bjbj LVҍ_ҍ_FF!F!F!F!F!Z!Z!Z!8!T!Z!\j"d""""$|~$D$$%\'\'\'\'\'\'\$J_bK\F!$$$$$K\F!F!""4`\%%%$dF!"F!"%\%$%\%%jUV![1NJ%X2\v\0\CXbJ%pbd![bF!![$$%$$$$$K\K\%$$$\$$$$b$$$$$$$$$X : Augusta University CONTRACT ROUTING AND APPROVAL FORMPlease complete this form and obtain all necessary approvals and signatures in boxes 1 3. ATTACH AT LEAST TWO ORIGINAL CONTRACTS (with all accompanying exhibits, attachments, and all other documents incorporated by reference in the contract) to this completed Form before submitting the package to the Office of Legal Affairs. 1. GENERAL INFORMATIONType of Contract / Brief Description: Contract Period: Start : End: Other Contracting Party: Is the Other Contracting Party a nonprofit organization? ____ (yes) ______ (no) Augusta University Contact Person For Contract: (Name) (Title) (Phone) (E-mail) (School/Center/Institute) (Department) 2. CERTIFICATION BY RESPONSIBLE AUGUSTA UNIVERSITY PERSONNELI have read the attached contract in its entirety. The contract accurately describes the agreement between the parties, including goods and/or services provided (for example, description of goods, delivery terms, statement of work) and obligations imposed (for example, manner and dates of payment, confidentiality provisions). I believe that the contract is in Augusta Universitys best interest that the activity is consistent with Augusta Universitys mission, and that Augusta University can perform its obligations in the contract. I accept responsibility for routing this contract and for managing it if it is executed. ______________________________________ _______________________________________ _______________________ (Signature) (Name) (Date) Approval by Dean of School / Vice President: The attached contract is approved. It is appropriate and necessary to the Schools /Augusta Universitys mission and priorities and such entity can furnish the services, materials, and/or funds designated in the contract. ___________________________________ _____________________________________________ ________________ (Signature) (Name - Title) (Date)  3. ROUTING AND APPROVALS Review by other Augusta University Departments/Offices/Units (if appropriate): I have reviewed the attached contract and [check one] Review by Office of Controller (for revenue producing contracts): [ FORMCHECKBOX ] have no objections, [ FORMCHECKBOX ] have certain concerns as set forth here: _______________ _____________________ ___________________ _____________ ______________ (Name) (Signature) (Title) (Date) (Phone) Review by SPA (for sponsored agreements): [ FORMCHECKBOX ] have no objections, [ FORMCHECKBOX ] have certain concerns [check one] as set forth here: __________________________________________________________________________________________________________ _______________ _____________________ ___________________ _____________ ______________ (Name) (Signature) (Title) (Date) (Phone) Review by the ITTSS (for contracts impacting information technology): [ FORMCHECKBOX ] have no objections, [ FORMCHECKBOX ] have certain concerns [check one] as set forth here: ____________________________________________ _______________ _____________________ ___________________ _____________ ______________ (Name) (Signature) (Title) (Date) (Phone) Review by the Enterprise Privacy Officer (for contracts involving Protected Health Information including business associate agreements): _____________________________________ ___________________ _____________ ______________ (Signature) (Title) (Date) (Phone) Review by _____________________________ [other Augusta University office]: [ FORMCHECKBOX ] have no objections, [ FORMCHECKBOX ] have certain concerns [check one] as set forth here: _____________________ ___________________ _____________ ______________ ________________ (Name) (Signature) (Title) (Date) (Phone) 4. 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