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BOARD OF PUBLIC WORKS <br />AGENDA, ITEM REVIEW RE' QUEST FORM <br />Date 10/04/2016 Department Fire <br />BPW Date 10/11/2016 Phone 9255 <br />Name Andrew Mver <br />Legal <br />Attorney Name Michael Srnidt <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller <br />[] <br />and greater than one year in length per the City Purchasing <br />Policy <br />o;-:. <br />Purchasing <br />❑ <br />Iii� Mir�,�:= <br />Agreement <br />❑ Contract J <br />El <br />Proposal -- - - <br />Addendum <br />❑ <br />Claim <br />❑ <br />Bid Opening <br />❑Bid <br />Award <br />❑ Re , to Advertise <br />I ❑ Title Sheet <br />Ll <br />Quote Opening <br />Quote Award <br />❑ <br />Chq Order No. <br />❑ <br />C/O & PGA No. <br />El <br />PCA <br />❑ <br />Ease./Encroach. <br />❑ <br />Traffic Control <br />❑ <br />Resolution <br />Other: <br />Company or Vendor Name Michiana Health Information Network <br />New Vendor <br />F1 <br />Yes <br />LJ No <br />El If Yes, Approved by Purchasing <br />MBENVBE Contractor <br />MBE I <br />WBE <br />Project Name <br />N/A <br />Project Number <br />N/A <br />-Funding Source <br />NIA <br />Account No. <br />N/A <br />Amount <br />$ 00.00 <br />Terms of Contract <br />Purpose/Description <br />The purpose of this a reement is to obtain medical data to <br />improve EMS Res onses for the City of South Bend. There will <br />be no mongy exhan ed for this agreement. <br />y <br />Amount of <br />D <br />❑ <br />Increase <br />Decrease <br />$ <br />$ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />PO No. <br />.,::uIs <br />... persa :. er•• pprova;....,::.:��.::::::.:::..::..:�::.:-��;:�.:�:�.:����:;�.:::'.;�:;::::��•�:�:•:.:::�:� <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />