Contract Approval Request Form
To Be Completed by Requesting Department (#1-21)
1) Date of Request: 4/29/2024
2) Contract Type: Expense
3) Renewal Contract: Yes
4) Department Name: Human Resources
5) Department Contact: Rebecca Gilliam
6) Description: Renewal of Interlocal Agreement with UTMB for Employee Health
7) PEID No: 402812
8) Req No:
9) Orgkey: 6123155023
10) Object Code: 5412010
11) Vendor: University of Texas Medical Branch (UTMB)
12) Vendor Contract No: CM23345
Expenditure Budget/Revenue Projections
13) Fund Name: Employee/Retiree Clinics
14) Fund #: 6123155023 5412010
15) Current Year Budgeted: $960,000
16) Current Year Projected: $960,000
17) Year 2:
18) Year 3:
19) Year 4:
20) Year 5:
21) Totals:
To Be Completed by Purchasing Department
22) Contract Start Date: 4/21/2024
23) Auto Renewal Contract: No
24) Bid No: NA
25) Contract End Date: 4/20/2025
26) Contract # Issued by Purchasing Department: CM23345
NOTES: HB1295 not required