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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]]<br />
[[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 />
<br />
Policy No.: '''8009'''<br />
Policy No.: '''8009'''<br />
Effective Date: '''11/01/06'''<br />
Effective Date: '''11/01/06'''<br />
Revised Date: '''Draft 11/9/21'''<br />
Revised Date: '''07/21/23'''<br />
Reviewed: <br />
Reviewed: '''07/21/23''' <br />
<br />
<br />
<big>'''Contracts Policy'''</big>
<big>'''Contracts Policy'''</big>
== Basis for 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 [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 to sign such contracts.
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==  
==Policy==  
=== Written Agreements Required ===
=== 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 the Board of Regents of the University of Nebraska, a public body corporate, on behalf of 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 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 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.
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 UNMC.  
===Digital Signatures===
 
====Contractually binding signatures governed by Executive Memoranda No. 13 and No. 14====
'''Delegation of Signature Authority'''
UNMC faculty and staff delegated signature authority through Executive Memoranda No. 13 and No. 14 shall utilize digital signature technology [https://sos.nebraska.gov/licensing/digital-signatures-certification-authorites certified by the Nebraska Secretary of State] in compliance with the [https://nebraskalegislature.gov/laws/statutes.php?statute=86-611 Nebraska Digital Signatures Act]. DocuSign is the current digital platform utilized by UNMC through an agreement with Nebraska Medicine (software license holder).<br />
 
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===
====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 [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 />
    
    
Access to DocuSign requires the submission and approval of the proposed use case by the UNMC department. There are four levels of use cases:<br />
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 />
 
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 />


:'''Level 1''' use of DocuSign will be for a signatory listed in Executive Memorandum No. 13 or 14 acting as a University Authorized Party to execute an agreement.<br />
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 />
:'''Level 2''' use of DocuSign will be for research participant e-consents.<br />
 
:'''Level 3''' use of DocuSign will be for non-binding signatures (UNMC internal forms/internal approvals).<br />
*'''Level 1''' contracts that a signatory listed in Executive Memorandum No. 13 or 14 acting as a University Authorized Party will execute.
:'''Level 4''' use of DocuSign will be for employment offer letters or designated Human Resource forms that are routed to a third party.<br />
*'''Level 2''' research participant e-consents (use of DocuSign requires the sponsor to contractually require use).
*'''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.<br />
Use case applications can encompass multiple levels if the DocuSign envelope creators are tasked with multiple uses of DocuSign.<br />
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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.
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.
===Executive Memorandum No. 14===
===Executive Memorandum No. 14===
{| class="wikitable"
{| class="wikitable"
|-
|-
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|-
| 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
| 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]
|-
|-
| PURCHASES OF GOODS AND SERVICES  || Procurement, [mailto:contracts@unmc.edu contracts@unmc.edu], https://info.unmc.edu/procurement/procurement/contracts/index.html
| 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
| LICENSED TECHNOLOGY  || UNeMed, 402-559-3274, https://www.unemed.com/contact-us/staff-directory
|-
|-
| BUSINESS FUNCTIONS || Business and Finance   
| BUSINESS FUNCTIONS || Business and Finance   
When UNMC is expending funds: 402-559-5400, [mailto:contracts@unmc.edu contracts@unmc.edu], https://info.unmc.edu/procurement/procurement/contracts/index.html
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: 402-559-5200, [mailto:alamer@unmc.edu Amy Lamer, Business Services, Risk Management Specialist] and copy [mailto:annebarnes@unmc.edu Vice Chancellor for Business and Finance and Business Development]


When UNMC is receiving revenue: 402-559-5200, [mailto:alamer@unmc.edu Amy Lamer] and copy [mailto:jeffrey.miller@unmc.edu Assistant Vice Chancellor for Business and Finance]  
Stewardship and management of resources issues: [mailto:mhrncirik@unmc.edu Assistant Vice Chancellor for Business and Finance], 402-559-5200
|-
|-
| ACADEMIC AGREEMENTS || Academic Affairs, 402-559-5130, https://www.unmc.edu/academicaffairs/compliance/affiliation-agreements.html, https://www.unmc.edu/academicaffairs/, https://www.unmc.edu/academicaffairs/about/index.html
| 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


|-
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[https://wiki.unmc.edu/index.php/Executive_Memo_14 Executive Memorandum 14 Contract Signature Authority] by position  
[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 Sarah Gloden Carlson, [mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer] at 402-559-9576.
Direct any questions related to the Contract Signature Authority to the [mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer] at 402-559-9576.


===Contract Types and Approvals===
===Contract Types and Signatories===
====Research Contracts====
====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.
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.
====Purchases of Goods and Services====
====Expenditure Contracts====
Procurement 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. Contracts for goods and services utilizing state funding must be reported through a state database under [https://nebraskalegislature.gov/bills/view_bill.php?DocumentID=18635 LB 429] [https://nebraskalegislature.gov/bills/view_bill.php?DocumentID=18635 (Legislative Bill)]. Procurement ensures that information security requirements are met for all [https://info.unmc.edu/procurement/_documents/contracts-quick-reference.pdf purchases].
=====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====
====Licensed Technology====
[https://www.unemed.com/contact-us/staff-directory UNeMed] focuses on promoting the advancement and commercialization of UNMC technologies. UNeMed signs agreements such as MTAs, CDAs, and Licensing Agreements where rights to UNMC intellectual property are utilized.
[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====
====Business Functions====
Agreements involving University stewardship and management of resources and revenue generating contracts are signed by Business and Finance.
Agreements involving University stewardship, management of resources and revenue generating contracts are executed by authorized signatories in Business and Finance.
====Academic Agreements====
====Academic Agreements====
[https://www.unmc.edu/academicaffairs/compliance/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 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.
[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==
==Data Security/Protected Health Information==
UNMC, as part of an [https://www.unmc.edu/hipaa/about/affiliated-covered-entity-structure.pdf Affiliated Covered Entity], 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 />
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 UNMC and Nebraska Medicine for equipment purchases or transfer of PHI electronically, a security review is required by [https://wiki.unmc.edu/index.php/Privacy/Information_Security Information Security].
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)==
==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).
[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==
==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 them 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 Agreement or Addendums Procedure]], an exception can only be approved by the University’s Office of the Vice President and General Counsel.
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==
==Additional Information==
*[mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer]
*[mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer]
*[mailto:jeffrey.miller@unmc.edu Assistant Vice Chancellor for Business and Finance]
*[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] and No. [https://info.unmc.edu/management/finance/business_services/SOP_8009_2_Digital_Signatures_Adobesign.pdf 8009.2]
*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://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=86-611 Nebraska Digital Signatures Act]
*[https://nebraskalegislature.gov/laws/statutes.php?statute=86-612 Uniform Electronics Transactions Act]
*[[Business Associate Agreements and Addendums Procedures]]
*[[Business Associate Agreements and Addendums Procedures]]
*[https://www.unmc.edu/hipaa/forms/index.html Business Associate Agreement template]  
*[https://www.unmc.edu/hipaa/forms/index.html Business Associate Agreement template]  
*[https://www.unmc.edu/academicaffairs/compliance/affiliation-agreements.html Academic Affiliation Agreements]
*[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])
*[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-personnel-actions.pdf Executive Memorandum 13], Delegation of Administrative Authority to Approve Academic-Administrative Personnel Actions