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[[Human Resources]] | [[Safety/Security]] | [[Research Compliance]] | '''[[Compliance]]''' | [[Privacy/Information Security]] | [[Business Operations]] | [[Intellectual Property]]
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[[Compliance Program]]&nbsp;| [[Compliance Hotline]]&nbsp;| [[Investigations by Third Parties]]&nbsp;| [[Research Integrity]]&nbsp;| [[Copyright]]&nbsp;| [[Export Control]]&nbsp; | [[Code of Conduct]]&nbsp; | [[Use of Human Anatomical Material]]&nbsp; | [[Clinical Trial Fee Billing Procedures]]&nbsp; | [[Contracts Policy]]&nbsp; | [[Conflicts of Interest]]
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<td style="padding:0.5em; background-color:white; line-height:0.95em; border:solid 2px #A3B1BF; border-bottom:0; font-weight:bold;" width="20">[[Compliance]]</td>
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</table>
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[[Compliance Program]] | [[Compliance Hotline]] | [[Investigations by Third Parties]] | [[Research Integrity]] | [[Export Control]] | [[Code of Conduct]] | [[Use of Human Anatomical Material]] | [[Clinical Research and Clinical Trial Professional and Technical Fee Billing]] | [[Contracts]] | [[Conflict of Interest]] | [[Red Flag Identity Theft Prevention Program]] | [[Principles of Financial Stewardship]] | [[Human Tissue Use and Transfer]] | [[Disclosing Foreign Support and International Activities]] | [[Health Care Vendor Interactions]] | [[Credit Hour Definition]] | [[Whistleblower]] | [[Electronic Digital Signatures and Records]]<br />
<br />
Policy No.: '''8009'''<br />
Effective Date: '''11/01/06'''<br />
Revised Date: '''07/09/24'''<br />
Reviewed: '''07/09/24'''<br />
<br />
<big>'''Contracts Policy'''</big>
== Basis for Policy ==
The purpose of this policy is to provide guidance on who is authorized to sign contracts on behalf of the University of Nebraska Medical Center and to make clear that individuals must have specific authority, as delegated in [https://nebraska.edu/offices-policies/policies Board of Regents Policy], in [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/delegation-of-administrative-authority-to-approve-certain-personnel-actions.pdf Executive Memorandum No. 13] and [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/delegation-of-administrative-authority-to-approve-certain-types-of-university-contracts.pdfExecutive Memorandum No. 14], and as specifically provided for in the UNMC Contract Signature Authority Tables ([https://wiki.unmc.edu/images/8/83/UNMC_Exec.Memo.13_Signature_Authority.pdf Executive Memorandum 13 Contract Signature Authority] by position, [https://wiki.unmc.edu/index.php/Executive_Memo_14 Executive Memorandum 14 Contract Signature Authority] by position) to sign such contracts. .  In addition, the purpose of this policy is to address the use of electronic and digital signatures in contracts.
==Policy==
=== Written Agreements Required ===
Written contracts are required, and all contracts shall be entered into by the Board of Regents of the University of Nebraska, a public body corporate, on behalf of the University of Nebraska Medical Center.


POLICY NO: '''8009'''<br />
'''Delegation of Signature Authority'''
EFFECTIVE DATE: '''11/01/06'''<br />
REVISED DATE: '''07/01/11'''<br />
REVIEWED DATE: '''07/01/11'''<br />


== Basis for Policy ==
Pursuant to University of Nebraska Executive Memorandum No. 14, the President has delegated authority to each Chancellor to approve specific types of contracts described in Section 4 of RP -6.3.1. Pursuant to University of Nebraska [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/delegation-of-administrative-authority-to-approve-certain-personnel-actions.pdf Executive Memorandum No. 13] and [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/delegation-of-administrative-authority-to-approve-certain-types-of-university-contracts.pdf Executive Memorandum No. 14], the Chancellor may further delegate contract signature authority. Individuals with the authority to sign contracts on behalf of UNMC are listed in the UNMC [https://wiki.unmc.edu/images/8/83/UNMC_Exec.Memo.13_Signature_Authority.pdf Executive Memorandum 13 Contract Signature Authority] and UNMC [https://wiki.unmc.edu/index.php/Executive_Memo_14 Executive Memorandum 14 Contract Signature Authority] Tables. No individual shall sign a contract on behalf of the University of Nebraska Medical Center unless having specifically been delegated the authority to do so.
   
===Electronic and Digital Signatures===
* [http://www.nebraska.edu/board/bylaws2006.pdf Section 6.4 of the Bylaws of the Board of Regents] (BOR) of the University of Nebraska Board of Regents Policy on Administrative Approval of University Contracts ([http://www.nebraska.edu/docs/board/RegentPolicies.pdf RP 6.3.1]) 
====Contractually Binding Signatures Governed by Executive Memoranda No. 13 and No. 14====
* University of Nebraska [http://www.nebraska.edu/docs/president/13%20Delegation%20to%20Approve%20Academic-Admin%20Personnel%20Actions.pdf Executive Memorandum 13], Delegation of Administrative Authority to Approve Academic-Administrative Personnel Actions 
UNMC employees delegated signature authority through Executive Memoranda No. 13 and No. 14 shall utilize UNMC approved digital and electronic signatures in compliance with the [https://nebraskalegislature.gov/laws/statutes.php?statute=86-611 Nebraska Digital Signatures Act] or the Uniform Electronic Transactions Act [https://nebraskalegislature.gov/laws/statutes.php?statute=86-612 Neb. Rev. Stat. § 86-612 ''et seq''.]. <br />
* [http://www.nebraska.edu/docs/president/14%20Authority%20to%20Approve%20Contracts.pdf University of Nebraska Executive Memorandum 14], Delegation of Administrative Authority to Approve Certain Types of University Contracts, and Requirements for Submittal and Execution of Contracts Requiring Approval by the Board of Regents 
 
* [http://www.nebraska.edu/docs/president/26%20Information%20Security%20Plan%20%28GLB%20Compliance%29.pdf University of Nebraska Executive Memorandum No. 26], Information Security Plan 
Internal documents, meaning documents signed between UNMC employees for purposes of internal UNMC business, may be executed with wet signatures, exchanged via email or via electronic or digital signature.<br />
* [http://www.nebraska.edu/docs/president/27%20HIPAA%20Compliance.pdf University of Nebraska Executive Memorandum No. 27], HIPAA Compliance Plan 
* [http://www.hhs.gov/ocr/hipaa/privrulepd.pdf Health Insurance Portability and Accountability Act of 1996] (HIPAA) [45 CFR §164.502(e)(1)] 
* [http://www.ftc.gov/privacy/glbact/ Gramm-Leach-Bliley Act] (GLBA)  [12 CFR §225.28] 


==Policy==                                                     
Contracts with parties external to UNMC should be signed via DocuSign. DocuSign is the current technology utilized by UNMC through an agreement with Nebraska Medicine (software license holder).<br />
'''Written Agreements Required'''. All organizations and individuals that provide products and services to the University of Nebraska Medical Center (UNMC) shall enter into a written contract with UNMC.  Pursuant to University of Nebraska Executive Memorandum No. 14, the President has delegated authority to each Chancellor to approve specific types of contracts described in Section 4 of RP -6.3.1.  Pursuant to [http://www.nebraska.edu/docs/president/13%20Delegation%20to%20Approve%20Academic-Admin%20Personnel%20Actions.pdf University of Nebraska Executive Memorandum No. 13] and [http://www.nebraska.edu/docs/president/14%20Authority%20to%20Approve%20Contracts.pdf Executive Memorandum No. 14], the Chancellor may delegate contract signature authority. Individuals with the authority to sign contracts on behalf of UNMC are listed in the [http://webmedia.unmc.edu/policy/ContractSignature.doc Contract Signature Authority Table]. (Changes to the Contract Signature Authority Table should be forwarded to the [mailto:wlawlor@unmc.edu Director, Financial Compliance and Cost Analysis].)


Original contracts are maintained as follows:
Access to DocuSign requires the submission of the proposed use case by the UNMC department and approval by the Assistant Vice Chancellor for Business and Finance. There are four (4) approved use cases:<br />
{| class="wikitable" width="75%"
|valign="top"| Student and Academic Program Affiliations:
|valign="top"| Vice Chancellor for Academic Affairs Office
|-
|valign="top"| Externally funded projects, including grants, contracts, cooperative<br \> agreements, subcontracts and other subrecipient & vendor agreements:
|valign="top"| Sponsored Programs Administration
|-
|valign="top"| Continuing Medical Education Program Agreements:
|valign="top"| Center for Continuing Education
|-
|valign="top"| All Others:
|valign="top"| Business Services
|}
<br />
'''Independent Contractors'''
<br />


Independent contractors are 3rd parties who perform services for or provide products to UNMC who are neither employees nor volunteers. The  [http://webmedia.unmc.edu/policy/8009IndepContTempl.doc Independent Contractor Agreement Template] shall be used when entering into contracts with independent contractors who perform non-clinical services (with the exception of sponsored programs agreements and continuing medical education program agreements).   For clinical service agreements, contact UNMC Physicians (UNMC-P) or University Dental Associates (UDA) administration, as applicable.   Questions regarding independent contractor status or requests to modify the template shall be directed to the Associate General Counsel for Health Care, Business Services, or Sponsored Programs Administration (for grants or sponsored programs agreements).
*'''Level 1''' contracts that a signatory listed in Executive Memorandum No. 13 or 14 acting as a University Authorized Party will execute.
*'''Level 2''' research participant e-consents (when DocuSign requires the sponsor to contractually require use and the research is NOT subject to FDA regulations).
*'''Level 3''' non-binding signatures (internal forms/internal approvals).
*'''Level 4''' employment offer letters or designated Human Resource forms that are routed to a third party.


* '''(A) Use of Protected Health Information (PHI) by an Outside Entity'''
Use case applications can encompass multiple levels if the DocuSign envelope creators are tasked with multiple uses of DocuSign.<br />


       
Audits of DocuSign activity are performed periodically to ensure that envelope creators are using DocuSign in compliance with the approved use case application. Use of DocuSign for unapproved use cases can result in the removal of access.<br />
:When a person or entity outside UNMC, The Nebraska Medical Center, UDA and UNMC-P performs a function or activity on behalf of UNMC that involves the use or disclosure of protected health information (PHI), the person or entity is a business associate of UNMC and a business associate addendum must be added to the contract for HIPAA compliance. Health care providers providing treatment are exempt from the business associate requirement.
       
:Academic affiliation agreement partners are not business associates.
       
:The [http://sapphire.nebraska.edu/standard/Business_forms.asp?Campus=UNMC&Want=Forms&Heading=HIPAA Business Associate Addendum] describes the permitted uses of the PHI and the business associate’s responsibilities regarding it. If a business associate relationship exists with no written contract, a [http://sapphire.nebraska.edu/standard/Business_forms.asp?Campus=UNMC&Want=Forms&Heading=HIPAA Business Associate Agreement] must be signed.       
       
* '''(B) Use of Protected Student Financial Information (PSFI) by an Outside Entity'''


       
Please refer to Standard Operating Procedures No. [https://info.unmc.edu/management/finance/business_services/SOP_8009_1_Digital_Signatures_Docusign.pdf 8009.1] for additional information.
:When a person or entity outside UNMC, The Nebraska Medical Center, UDA, and UNMC-P performs a function or activity on behalf of UNMC that involves protected student financial information (PSFI), a [https://unebapps01.nebraska.edu/slugo/download.nsf/UNMCWinFile?OpenView&Start=1&Count=50&Expand=2.3 Gramm-Leach-Bliley Act] (GLBA) Addendum must be added to the contract for GLBA compliance.
===Executive Memorandum No. 14===
       
{| class="wikitable"
:The GLBA addendum describes the permitted uses of the PSFI and the service provider’s responsibilities regarding it. If a service provider relationship exists with no written contract, a GLBA agreement must be signed.     
|-
!Category!! Authorities
|-
| RESEARCH CONTRACTS, meaning federal awards, research grants and contracts and externally funded research related projects|| Sponsored Programs Administration, 402-559-7456, https://www.unmc.edu/spa/about/contact.html
Authorized Organization Representative and [mailto:ckratoch@unmc.edu Associate Vice Chancellor for Clinical Research]


       
UNeHealth, https://www.unmc.edu/spa/clinical-trials/unehealth/
* '''(C) Use of UNMC Information Systems''' 


       
Clinical Research Center, https://www.unmc.edu/cctr/resources/crc/index.html
:When a person or entity outside UNMC, The Nebraska Medical Center, UDA and UNMC-P (“service provider”) requires electronic access to UNMC private network resources, and is not a business associate, the service provider shall sign a [http://sapphire.nebraska.edu/standard/Business_forms.asp?Campus=UNMC&Want=Forms&Heading=HIPAA Business Partner Agreement or Addendum].
|-
| PURCHASES OF GOODS AND SERVICES  || Procure to Pay, [mailto:contracts@nebraska.edu contracts@nebraska.edu]
|-
| LICENSED TECHNOLOGY  || UNeMed, 402-559-3274, https://www.unemed.com/contact-us/staff-directory
|-
| BUSINESS FUNCTIONS || Business and Finance 
When UNMC is expending funds or procuring goods or services: Procure to Pay, [mailto:contracts@nebraska.edu contracts@nebraska.edu]


       
When UNMC is receiving revenue: 402-559-5221, [mailto:alamer@unmc.edu Amy Lamer, Business Services, Risk Management Specialist] and copy [mailto:mhrncirik@unmc.edu Assistant Vice Chancellor for Business and Finance]
:[http://sapphire.nebraska.edu/standard/html/wa08_Business_forms.asp?Campus=UNMC&Want=Forms&Heading=HIPAA Academic Affiliation Agreements].  Academic Affiliation agreements are required for all organizations accepting UNMC students and for all students who come to UNMC from other educational institutions for clinical experience. The academic affiliation template shall be used. Any modifications to the academic affiliation template must be approved by the Office of the Vice Chancellor for Academic Affairs. A fully executed original copy of the agreement is kept on file in the Office of the Vice Chancellor for Academic Affairs.<br />
<br />


== Definitions ==
Stewardship and management of resources issues: [mailto:mhrncirik@unmc.edu Assistant Vice Chancellor for Business and Finance and Controller], 402-559-5837
|-
| ACADEMIC AGREEMENTS || Academic Affairs, 402-559-5130, https://info.unmc.edu/policies/academicaffairs/affiliation-agreements.html, https://www.unmc.edu/academicaffairs/, https://www.unmc.edu/academicaffairs/about/index.html


'''Business Associate''' is defined as a person or entity outside UNMC, The Nebraska Medical Center, University Dental Associates (UDA), and UNMC Physicians (UNMC-P) (the affiliated covered entity) that performs a function or activity on behalf of UNMC that involves the use or disclosure of protected health information (PHI). Health care providers providing treatment are exempt from the business associate requirements.<br \><br \>
|-
| All Others || See Contract Signature Authority Tables: [https://wiki.unmc.edu/images/8/83/UNMC_Exec.Memo.13_Signature_Authority.pdf Executive Memorandum 13 Contract Signature Authority] by position and
[https://wiki.unmc.edu/index.php/Executive_Memo_14 Executive Memorandum 14 Contract Signature Authority] by position
|}
Direct any questions related to the Contract Signature Authority to the [mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer] at 402-559-9576.


'''Independent Contractors''' are individuals or entities who perform services for or provide goods to UNMC, who are not employees or volunteers.  The Internal Revenue Service (IRS) test for independent contractor status depends on three factors: behavioral control, financial control, and relationship of the parties. The general rule is that an individual is an independent contractor if the entity receiving services has the right to control or direct only the result of the work and not the means and methods of accomplishing the work. For more information about independent contractor determination, see [http://www.irs.ustreas.gov/pub/irs-pdf/p1779.pdf IRS Publications 1779] and [http://www.irs.gov/pub/irs-pdf/p15a.pdf 15-A].<br \><br \>
===Contract Types and Signatories===
'''Protected Health Information (PHI)''' is individually identifiable health information. Health information means any information, whether oral or recorded in any medium, that:
====Research Contracts====
   
In compliance with Federal regulations, an individual designated as Authorized Organization Representative (AOR) is the only official authorized to sign on behalf of the institution. Signature by the AOR signifies that the University agrees to comply with regulations and laws. Sponsored Programs Administration is the authorized signature official of UNMC for sponsored programs grants and contracts.
# is created or received by UNMC; and
====Expenditure Contracts====
# relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.<br />
=====Purchases of Goods and Services=====
Procure to Pay (P2P) is responsible for contracts where University funds are spent. The Board of Regents Policies and Bylaws provide thresholds that trigger bidding requirements, signature authority and other requirements. Contracts for procurements utilizing state funding must be reported to the Nebraska State Contracts Database in accordance with the Nebraska Taxpayer Transparency Act [https://nebraskalegislature.gov/laws/statutes.php?statute=84-602.03 Neb. Rev. Stat. § 84-602.01 ''et seq.'']. P2P ensures that information security requirements are met for all purchases.
====Licensed Technology====
[https://www.unemed.com/contact-us/staff-directory UNeMed] focuses on promoting the advancement and commercialization of UNMC technologies. UNeMed authorized signatories execute agreements such as material transfer agreements, confidentiality and nondisclosure agreements, and licensing agreements where rights to UNMC intellectual property are utilized.
====Business Functions====
Agreements involving University stewardship, management of resources and revenue generating contracts are executed by authorized signatories in Business and Finance.
====Academic Agreements====
[https://info.unmc.edu/policies/academicaffairs/affiliation-agreements.html Academic Affiliation Agreements] are required for all organizations accepting UNMC students and for all students who come to UNMC from other educational institutions for clinical or nonclinical experience [mailto:jobshadow@nebraskamed.com (Office of Health Professions Education)]. Academic Affiliation Agreements are approved by the [https://www.unmc.edu/academicaffairs/about/index.html Office of the Senior Vice Chancellor for Academic Affairs]. Contact your college representative responsible for drafting and negotiating Academic Affiliation Agreements or Academic Affairs at 402-559-5130 with questions.
==Data Security/Protected Health Information==
UNMC, as a party to an [https://www.unmc.edu/hipaa/about/affiliated-covered-entity-structure.pdf Affiliated Covered Entity Agreement (ACE)], is obligated to protect patient information under HIPAA. Any UNMC contract that involves the disclosure of protected health information (PHI) outside of UNMC and/or Nebraska Medicine must ensure that procedures and policies are followed to secure PHI. <br />
<br />
<br />
When contracting outside of the ACE for software, equipment purchases or transfer of PHI electronically, a security review is required by [https://wiki.unmc.edu/index.php/Privacy/Information_Security Information Security].
==Protected Student Financial Information (PSFI)==
[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/university-of-nebraska-information-security-plan.pdf University of Nebraska Executive Memorandum No. 26] describes protections of Student Financial Information required under Gramm Leach Bliley Act (GLBA), and protection of credit card information received in the course of business. When an activity requires use of protected financial information under Executive Memorandum No. 26, a GLBA Addendum must be added to the contract (the Addendum is attached as an exhibit to Memorandum 26).
==Business Associate Agreement/Addendum==
A business associate relationship exists when a person/entity outside of the ACE performs a function or activity on behalf of the ACE that requires business associates to use or disclose protected health information (PHI) in order to perform the function. If a business associate relationship exists with no written contract, a business associate agreement must be signed. If there is an existing contract with the business associate, a business associate addendum must be added. The [https://www.unmc.edu/hipaa/forms/index.html Business Associate Agreement template] can be located at https://www.unmc.edu/hipaa/forms/index.html. Refer to the [https://www.unmc.edu/hipaa/forms/docs/wedi-ba-decision-tree-v2.pdf Business Associate Decision Tree] as needed. All Business Associates are required to implement all HIPAA Security Rule Safeguards. In the event that a vendor cannot meet a specific requirement of the [[Business Associate Agreements and Addendums Procedures|Business Associate Agreement or Addendums Procedure]], an exception can only be approved by the Vice Chancellor for Business, Finance and Business Development and the University’s Office of the Vice President and General Counsel.
==Additional Information==
*[mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer]
*[mailto:mhrncirik@unmc.edu Assistant Vice Chancellor for Business and Finance]
*Standard Operating Procedures No. [https://info.unmc.edu/management/finance/business_services/SOP_8009_1_Digital_Signatures_Docusign.pdf 8009.1]
*[https://sos.nebraska.gov/licensing/digital-signatures-certification-authorites Digital Signatures Certification Authorities certified by the Nebraska Secretary of State]
*[https://nebraskalegislature.gov/laws/statutes.php?statute=86-611 Nebraska Digital Signatures Act]
*[https://nebraskalegislature.gov/laws/statutes.php?statute=86-612 Uniform Electronics Transactions Act]
*[[Business Associate Agreements and Addendums Procedures]]
*[https://www.unmc.edu/hipaa/forms/index.html Business Associate Agreement template]
*[https://info.unmc.edu/policies/academicaffairs/affiliation-agreements.html Academic Affiliation Agreements]
*[https://nebraska.edu/docs/board/bylaws.pdf Section 6.4 of the Bylaws of the Board of Regents] of the University of Nebraska Board of Regents Policy on Administrative Approval of University Contracts ([https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/board-governing-documents/board-of-regents-policies.pdf RP – 6.3.1])
*University of Nebraska [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/delegation-of-administrative-authority-to-approve-certain-personnel-actions.pdf Executive Memorandum 13], Delegation of Administrative Authority to Approve Academic-Administrative Personnel Actions
*University of Nebraska [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/delegation-of-administrative-authority-to-approve-certain-types-of-university-contracts.pdf Executive Memorandum 14], Delegation of Administrative Authority to Approve Certain Types of University Contracts, and Requirements for Submittal and Execution of Contracts Requiring Approval by the Board of Regents
*University of Nebraska Executive Memorandum No. 26 [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/university-of-nebraska-information-security-plan.pdf Information Security Plan - Gramm Leach Bliley Compliance]
*University of Nebraska [https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/hipaa-compliance-policy.pdf Executive Memorandum No. 27], HIPAA Compliance Plan 
*[http://www.gpo.gov/fdsys/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf Health Insurance Portability and Accountability Act of 1996] (HIPAA) [45 CFR §164.502(e)(1)] 
*[http://www.gpo.gov/fdsys/pkg/PLAW-106publ102/pdf/PLAW-106publ102.pdf Gramm-Leach-Bliley Act](GLBA) 12 CFR §225.28] 
*Contract Signature Authority Tables
**[https://wiki.unmc.edu/images/8/83/UNMC_Exec.Memo.13_Signature_Authority.pdf Executive Memorandum 13 Contract Signature Authority] by position
**[https://wiki.unmc.edu/index.php/Executive_Memo_14 Executive Memorandum 14 Contract Signature Authority] by position
*IRS Publication [http://www.irs.gov/pub/irs-pdf/p15a.pdf 15-A]


'''Protected Student Financial Information (PSFI)''' is information that UNMC has obtained from a student in the process of offering a financial product or service, or such information provided to UNMC by another financial institution.  Offering a financial product or service includes offering student loans to students, receiving tax information from a student’s parent when offering a financial aid package and other financial services.  Examples of student financial information include addresses, phone numbers, bank and credit account numbers, income and credit histories, and social security numbers in both paper and electronic format.<br \><br \>
For additional information, please contact the [mailto:swrobel@unmc.edu Compliance Officer] or the [mailto:kswartsl@unmc.edu Director, Business Services], or see [[Business Associate Agreements and Addendums Procedures]].
[http://webmedia.unmc.edu/policy/ContractSignature.doc Contract Signature Authority Table] / [http://webmedia.unmc.edu/policy/8009IndepContTempl.doc Independent Contractor Agreement Template]
[http://sapphire.nebraska.edu/standard/Business_forms.asp?Campus=UNMC&Want=Forms&Heading=HIPAA Business Partner Agreement or Addendum] /
[http://sapphire.nebraska.edu/standard/Business_forms.asp?Campus=UNMC&Want=Forms&Heading=HIPAA Business Associate Agreements and Addendums]
<br />


This page maintained by [mailto:dpanowic@unmc.edu dkp].
This page maintained by [mailto:mhurlocker@unmc.edu mh].

Latest revision as of 14:06, July 26, 2024

Human Resources   Safety/Security   Research Compliance   Compliance   Privacy/Information Security   Business Operations   Intellectual Property   Faculty


Compliance Program | Compliance Hotline | Investigations by Third Parties | Research Integrity | Export Control | Code of Conduct | Use of Human Anatomical Material | Clinical Research and Clinical Trial Professional and Technical Fee Billing | Contracts | Conflict of Interest | Red Flag Identity Theft Prevention Program | Principles of Financial Stewardship | Human Tissue Use and Transfer | Disclosing Foreign Support and International Activities | Health Care Vendor Interactions | Credit Hour Definition | Whistleblower | Electronic Digital Signatures and Records

Policy No.: 8009
Effective Date: 11/01/06
Revised Date: 07/09/24
Reviewed: 07/09/24

Contracts Policy

Basis for Policy

The purpose of this policy is to provide guidance on who is authorized to sign contracts on behalf of the University of Nebraska Medical Center and to make clear that individuals must have specific authority, as delegated in Board of Regents Policy, in Executive Memorandum No. 13 and Memorandum No. 14, and as specifically provided for in the UNMC Contract Signature Authority Tables (Executive Memorandum 13 Contract Signature Authority by position, Executive Memorandum 14 Contract Signature Authority by position) to sign such contracts. .  In addition, the purpose of this policy is to address the use of electronic and digital signatures in contracts.

Policy

Written Agreements Required

Written contracts are required, and all contracts shall be entered into by the Board of Regents of the University of Nebraska, a public body corporate, on behalf of the University of Nebraska Medical Center.

Delegation of Signature Authority

Pursuant to University of Nebraska Executive Memorandum No. 14, the President has delegated authority to each Chancellor to approve specific types of contracts described in Section 4 of RP -6.3.1. Pursuant to University of Nebraska Executive Memorandum No. 13 and Executive Memorandum No. 14, the Chancellor may further delegate contract signature authority. Individuals with the authority to sign contracts on behalf of UNMC are listed in the UNMC Executive Memorandum 13 Contract Signature Authority and UNMC Executive Memorandum 14 Contract Signature Authority Tables. No individual shall sign a contract on behalf of the University of Nebraska Medical Center unless having specifically been delegated the authority to do so.

Electronic and Digital Signatures

Contractually Binding Signatures Governed by Executive Memoranda No. 13 and No. 14

UNMC employees delegated signature authority through Executive Memoranda No. 13 and No. 14 shall utilize UNMC approved digital and electronic signatures in compliance with the Nebraska Digital Signatures Act or the Uniform Electronic Transactions Act Neb. Rev. Stat. § 86-612 et seq..

Internal documents, meaning documents signed between UNMC employees for purposes of internal UNMC business, may be executed with wet signatures, exchanged via email or via electronic or digital signature.

Contracts with parties external to UNMC should be signed via DocuSign. DocuSign is the current technology utilized by UNMC through an agreement with Nebraska Medicine (software license holder).

Access to DocuSign requires the submission of the proposed use case by the UNMC department and approval by the Assistant Vice Chancellor for Business and Finance. There are four (4) approved use cases:

  • Level 1 contracts that a signatory listed in Executive Memorandum No. 13 or 14 acting as a University Authorized Party will execute.
  • Level 2 research participant e-consents (when DocuSign requires the sponsor to contractually require use and the research is NOT subject to FDA regulations).
  • Level 3 non-binding signatures (internal forms/internal approvals).
  • Level 4 employment offer letters or designated Human Resource forms that are routed to a third party.

Use case applications can encompass multiple levels if the DocuSign envelope creators are tasked with multiple uses of DocuSign.

Audits of DocuSign activity are performed periodically to ensure that envelope creators are using DocuSign in compliance with the approved use case application. Use of DocuSign for unapproved use cases can result in the removal of access.

Please refer to Standard Operating Procedures No. 8009.1 for additional information.

Executive Memorandum No. 14

Category Authorities
RESEARCH CONTRACTS, meaning federal awards, research grants and contracts and externally funded research related projects Sponsored Programs Administration, 402-559-7456, https://www.unmc.edu/spa/about/contact.html

Authorized Organization Representative and Associate Vice Chancellor for Clinical Research

UNeHealth, https://www.unmc.edu/spa/clinical-trials/unehealth/

Clinical Research Center, https://www.unmc.edu/cctr/resources/crc/index.html

PURCHASES OF GOODS AND SERVICES Procure to Pay, contracts@nebraska.edu
LICENSED TECHNOLOGY UNeMed, 402-559-3274, https://www.unemed.com/contact-us/staff-directory
BUSINESS FUNCTIONS Business and Finance

When UNMC is expending funds or procuring goods or services: Procure to Pay, contracts@nebraska.edu

When UNMC is receiving revenue: 402-559-5221, Amy Lamer, Business Services, Risk Management Specialist and copy Assistant Vice Chancellor for Business and Finance

Stewardship and management of resources issues: Assistant Vice Chancellor for Business and Finance and Controller, 402-559-5837

ACADEMIC AGREEMENTS Academic Affairs, 402-559-5130, https://info.unmc.edu/policies/academicaffairs/affiliation-agreements.html, https://www.unmc.edu/academicaffairs/, https://www.unmc.edu/academicaffairs/about/index.html
All Others See Contract Signature Authority Tables: Executive Memorandum 13 Contract Signature Authority by position and

Executive Memorandum 14 Contract Signature Authority by position

Direct any questions related to the Contract Signature Authority to the Chief Compliance Officer at 402-559-9576.

Contract Types and Signatories

Research Contracts

In compliance with Federal regulations, an individual designated as Authorized Organization Representative (AOR) is the only official authorized to sign on behalf of the institution. Signature by the AOR signifies that the University agrees to comply with regulations and laws. Sponsored Programs Administration is the authorized signature official of UNMC for sponsored programs grants and contracts.

Expenditure Contracts

Purchases of Goods and Services

Procure to Pay (P2P) is responsible for contracts where University funds are spent. The Board of Regents Policies and Bylaws provide thresholds that trigger bidding requirements, signature authority and other requirements. Contracts for procurements utilizing state funding must be reported to the Nebraska State Contracts Database in accordance with the Nebraska Taxpayer Transparency Act Neb. Rev. Stat. § 84-602.01 et seq.. P2P ensures that information security requirements are met for all purchases.

Licensed Technology

UNeMed focuses on promoting the advancement and commercialization of UNMC technologies. UNeMed authorized signatories execute agreements such as material transfer agreements, confidentiality and nondisclosure agreements, and licensing agreements where rights to UNMC intellectual property are utilized.

Business Functions

Agreements involving University stewardship, management of resources and revenue generating contracts are executed by authorized signatories in Business and Finance.

Academic Agreements

Academic Affiliation Agreements are required for all organizations accepting UNMC students and for all students who come to UNMC from other educational institutions for clinical or nonclinical experience (Office of Health Professions Education). Academic Affiliation Agreements are approved by the Office of the Senior Vice Chancellor for Academic Affairs. Contact your college representative responsible for drafting and negotiating Academic Affiliation Agreements or Academic Affairs at 402-559-5130 with questions.

Data Security/Protected Health Information

UNMC, as a party to an Affiliated Covered Entity Agreement (ACE), is obligated to protect patient information under HIPAA. Any UNMC contract that involves the disclosure of protected health information (PHI) outside of UNMC and/or Nebraska Medicine must ensure that procedures and policies are followed to secure PHI.

When contracting outside of the ACE for software, equipment purchases or transfer of PHI electronically, a security review is required by Information Security.

Protected Student Financial Information (PSFI)

University of Nebraska Executive Memorandum No. 26 describes protections of Student Financial Information required under Gramm Leach Bliley Act (GLBA), and protection of credit card information received in the course of business. When an activity requires use of protected financial information under Executive Memorandum No. 26, a GLBA Addendum must be added to the contract (the Addendum is attached as an exhibit to Memorandum 26).

Business Associate Agreement/Addendum

A business associate relationship exists when a person/entity outside of the ACE performs a function or activity on behalf of the ACE that requires business associates to use or disclose protected health information (PHI) in order to perform the function. If a business associate relationship exists with no written contract, a business associate agreement must be signed. If there is an existing contract with the business associate, a business associate addendum must be added. The Business Associate Agreement template can be located at https://www.unmc.edu/hipaa/forms/index.html. Refer to the Business Associate Decision Tree as needed. All Business Associates are required to implement all HIPAA Security Rule Safeguards. In the event that a vendor cannot meet a specific requirement of the Business Associate Agreement or Addendums Procedure, an exception can only be approved by the Vice Chancellor for Business, Finance and Business Development and the University’s Office of the Vice President and General Counsel.

Additional Information


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