Contract Approval Request Form
To Be Completed by Requesting Department (#1-22)
1) Date of Request: 9/28/2026
2) Contract Type: Expense
3) Renewal Contract: Yes
4) Department Name: Professional Services
5) Department Contact: Diana Huallpa
6) Description: Physician Assistant Contract - CPS case related exams & associated services
7) Fund Name and Number: 1206 Child Welfare Fund
8) Cost Center: 443300
9) Ledger Account Summary: 5412000
10) Spend Category: Physician’s Assistant
11) Project Worktag (when applicable):
12) Grant Worktag (when applicable):
13) Vendor: University of Texas Medical Branch
14) Vendor Contract Number: ☐ Yes ☐ No: Click or tap here to enter text.
Expenditure Budget/Revenue Projections
15) Budget Amendment Requested: ☐ Yes ☒ No (if yes, provide BA request details): Click or tap here to enter text.
16) Current Year Budgeted: $191,000
17) Current Year Projected: $191,000
18) Year 2:
19) Year 3:
20) Year 4:
21) Year 5:
22) Totals: $191,000
To Be Completed by Purchasing Department
23) Contract Start Date: 10/1/2026
24) Auto Renewal Contract: No
25) Bid No: N/A
26) Contract End Date: 9/30/2027
27) Contract # Issued by Purchasing Department: SC-0000995
NOTES: