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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 4/30/2018 <br />Name Andrew Myer, Assistant Chief/EMS Department Fire <br />BPW Date May 8 th, 2018 Phone Extension 9255 <br />Required Prior to Submittal to Board <br />Legal X Attorney Name Anderson, Elliot <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller X and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing X Michael Schmidt <br />X Agreement <br />F-1 Contract <br />❑ Proposal LJ Addendum <br />El Professional Services <br />F Amendment <br />F1 Bid Opening <br />F Bid Award <br />E] Req. to Advertise ❑ Title Sheet <br />0 Quote Opening <br />EJ Quote Award <br />F Chg Order No. <br />El C/O & PCA No. <br />F1 PCA <br />E] Ease./Encroach. <br />❑ Traffic Control <br />F] Resolution <br />F Other: <br />El Claim <br />Company or Vendor Name Michiiana Health Information Network — <br />F Yes E] If Yes, Approved by Purchasing <br />New Vendor <br />X INo <br />MBEANBE Contractor <br />MBE WBE ❑Nos <br />Completed E-Verify Form Attached <br />Project Name <br />Project Number <br />Funding Source <br />Professional Services <br />Account No. <br />288.0902.422.31-06 <br />Amount <br />$1 0,776.00 <br />Terms of Contract <br />Annual subscription <br />Purpose/Description <br />Software and records management for Mobile Integrated <br />Community Health Outreach Program (Community <br />Paramedicine) <br />For Change Orders Only <br />Amount of E] <br />❑ <br />Increase $ <br />Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: % <br />New Amount <br />$ <br />Total Percent of Change: % <br />Time Extension: <br />Dispersal After Approval <br />Copy Original <br />FIX F-1 <br />Andy Myer <br />RX 0 <br />Todd Skwarcan <br />El El <br />