Contract Agreement Request - Meadows Mental Health Policy Institute

Please take a moment before starting your submission form to consider if your project aligns with a service and requires a Statement of Work. If so, please download the SOW template, fill out the Word document, and upload your SOW using our upload selection at the end of the submission below.

Salesforce Contract / Agreement Request

"*" indicates required fields

General Information

Today's Date

MM slash DD slash YYYY

Contracts Team Point of Contact*

Your Name*

First Last

Email*

Is there a submission due date?

Yes

What is the submission due date?

MM slash DD slash YYYY

Project Name

Select the Type of Agreement

Revenue or Money In

Expense or Money-Out

MOU

Sub-Contract or Sub-Grant

Amendment to an existing agreement

Confidentiality/Non-Disclosure Agreement (NDA)

Other

Please select the information sharing agreement type.

Will confidential information be shared just from MMHPI to the other entity (NDA) or will both entities be sharing confidential information with one another (Mutual NDA)?

One-way Information Sharing

Mutual Information Sharing

I don't know

Please provide a one sentence description of the purpose of the engagement between MMHPI and the other entity.

(e.g., “conducting preliminary discussions in contemplation of an agreement to collaborate or form a business relationship”; “collaborating and co-developing a proposal in response to [specific RFP title], dated [XX/XX/XXX]”; “in connection with [existing agreement/contract]”).

What is the Budget Line Item Number for this expense?*

*The Budget Line Item Number refers to the reference number listed in the annual MMHPI budget, starting with the budget year (e.g., 25-XXXX). If this expense does not have a Budget Line Item Number, enter “None”. If you have questions, please reach out to Maryana Geller at mgeller@mmhpi.org.

What is the Budget Line Item Number* for this revenue?*

*The Budget Line Item Number refers to the reference number listed in the annual MMHPI budget, starting with the budget year (e.g., 25-XXXX). If this revenue source does not have a Budget Line Item Number, enter “None”. If you have questions, please reach out to Maryana Geller at mgeller@mmhpi.org.

Is this expense connected to an existing revenue source?

Yes

If yes, please provide the funder and project name.

Does this contract involve pass-through Federal funding?

Yes

I don’t know

Is the funder a for-profit, industry, or corporate entity?

Yes

I don’t know

Please Describe the Agreement

Which option best describes the Intellectual Property (IP) ownership arrangement for this agreement?

MMHPI has full ownership; Consultant has no rights to use

MMHPI has primary ownership, Consultant has limited license to use internally

MMHPI has primary ownership, Consultant has broad license to use and modify deliverables for internal/external use (i.e., essentially secondary ownership)

Consultant maintains ownership; MMHPI has full license to use

I am not sure/need more information

Include the Optional Early Termination Language*

Yes

I do not know

* The early termination language requires the consultant to payback the Meadows Institute for any advanced payments already made. In the event MMHPI terminates this Agreement as a result of Consultant’s breach or failure to perform the Services to MMHPI’s satisfaction, MMHPI may require Consultant to refund, and Consultant shall pay to MMHPI within five (5) days of MMHPI’s demand therefor, any and all amounts deemed reasonable by MMHPI to have been paid or advanced by MMHPI to Consultant under this Agreement for Services not satisfactorily performed by Consultant.

Will there be any subcontractors on this project?

Please list any subcontractors, one per line.

Effective / Start Date

MM slash DD slash YYYY

Completion / End Date

MM slash DD slash YYYY

OST Member responsible for project.

Chief of Staff for project

Source Team

(i.e., team responsible for bringing this project forward)

Does this contract require a new TSheets code?

Yes

No, a TSheets code isn’t needed

No, a TSheets code already exists

I don’t know

Organization Information

Entity Name

Type of Entity

If you selected Type of Entity, Other would you please describe?

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code

Primary Point of Contact

Name

First Last

Title

Phone

Contracts / Administration Point of Contact

Same as the Primary Point of Contact?

Yes

Name

First Last

Title

Phone

Signatory Point of Contact

Same as the Primary Point of Contact?

Yes

Name

First Last

Title

Phone

Statement of Work

Add Your Statement of Work

Please upload a completed SOW document. You can view the MMHPI example SOW here.

Drop files here or

Accepted file types: pdf, doc, docx, dotx, Max. file size: 50 MB, Max. files: 5.

Are there any other additional notes that you would like to add?

Yes

Please provide additional details you would like to include that haven’t been provided in previous fields?

Salesforce Contract / Agreement Request

General Information

Organization Information

Primary Point of Contact

Contracts / Administration Point of Contact

Signatory Point of Contact

Statement of Work

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