Version 07 2019
AGREEMENT ROUTING FORM COLLEGE OF MEDICINE and FAMILY MEDICINE
TO: Contract Office, Box 70729 Contract Number_________________________
(Assigned by Contract Office)
TO BE COMPLETED BY DEPARTMENT:
Amount $_________________
Expense
Revenue No Cost
Chart & Index ____ - ____________
Contract Term: _________________ to __________________
# of Renewals _________
ETSU Department: _________________________________ Responsible Person: _______________________________
Contractor Name: _____________________________________________ Contractor E# _______________________
Contractor Address: _______________________________________________________________________________
Purpose of Agreement: _____________________________________________________________________________
If this agreement is $10,000 or more provide the bid documentation or sole source justification.
Type of Agreement:
AAMC Training
Facility Usage
Preceptor
Sponsorship
Business Associate
International Studies
Resident Rotation
Clinical Affiliation
License Software
Service w/ Business
Dual Services
MEAC
Service w/ Person
Amendment to Contract # ____________________
I hereby declare that the information provided in this document is true and correct and that I have sufficient knowledge of
authority and responsibility for the work to be performed under this agreement to effectively make this certification.
_______________________________________ _________ ______________________________________ _________
Signature of individual completing this form Date Approval Date
Department: ____________________________________________________________ Box #: ___________
Name: _____________________________________________________ Phone: ______________________
____________________________ ___________ ____________________________ __________
Associate Dean Date Dean Date
Return by mail to COM F&A, Building 178, P.O. Box 70420
FOR CONTRACT OFFICE USE ONLY
Encumber Yes No Financial Consideration $_____________
To be signed by: Pres AA Admin Ath B&F HA SA UA
Reviewed for content by University Attorney:
If this agreement is for SERVICES with a PERSON complete the following:
Is this payment being made to or on behalf of a U.S. citizen or legal permanent resident? Yes No
If no, contact the Office of Nonresident Alien Tax Compliance at 423-439-6887 or criggerj@etsu.edu
Is the PERSON an employee of ETSU, another State/TBR school, or a State of Tennessee agency? Yes No
A.) Do other ETSU employees perform essentially the same duties that are to be performed by this PERSON? Yes No
B.) Has this PERSON previously been paid as an ETSU employee to perform essentially these same tasks? Yes No
If the answer to question A and/or B is YES, the worker must be classified as an employee and hired in accordance with personnel policies.
If the answers to questions A and B are both NO, the Employee vs. Independent Contractor Classification Criteria form must be completed:
https://www.etsu.edu/bf/documents/employeevscontractor.pdf