ࡱ> ` dbjbjss z%4& $$$hF%t%YJ&B)"d)d)d)e0u12TXXXXXXX$R[h]~Xw3.e0w3w3Xd)d)wlY888w3d)d)X8w3X886TVd)>& Y؎$ 40}UVY0YU<8^;58^8V8^V(m202"822m2m2m2XX8|m2m2m2Yw3w3w3w3$$4," OFFICIAL COLORADO STATE DOCUMENT DO NOT ALTER THIS FORMCERTIFICATION FOR PERSONAL SERVICES AGREEMENTS Additional supporting documentation may need to be provided in addition to the completion of this form in its entirety. Contact your departments human resource office for assistance. Department/Institution Name:  FORMTEXT       Contract Routing/PO Number:  FORMTEXT       Modification #:  FORMTEXT      Original Total $ Amount:  FORMTEXT      New Total $ Amount:  FORMTEXT       Contracting Company:  FORMTEXT      Assigned Individual Contractor/Leased Worker(s):  FORMTEXT       TERM OF AGREEMENTFrom:  FORMTEXT      To:  FORMTEXT      If this is a modification, please explain the reason for the modification including any difference in scope from the original contract. (Extensions, renewals, or decrease in services or funding do not require personal services review).  FORMTEXT       Please provide an explanation of the services being outsourced, including the type of services, skills and expertise to be purchased, how and why it is a specialized skill, and identify the direct beneficiary of the services.  FORMTEXT       Post April 7, 1993, are there specific statutory citations (not footnotes to the Long Bill) that require an outside contractor to provide this service? No  FORMCHECKBOX  FORMTEXT    Yes  FORMTEXT    FORMCHECKBOX  If yes, cite statute. C.R.S.  FORMTEXT       Have the services proposed for outsourcing been performed by state personnel system staff? No  FORMCHECKBOX  FORMTEXT    Yes  FORMCHECKBOX  FORMTEXT    If yes, provide the following: When?  FORMTEXT       What job class was utilized?  FORMTEXT       Why did the department decide to contract out these services?  FORMTEXT       Are these services ongoing for an indefinite period of time? No  FORMTEXT    Yes  FORMCHECKBOX  FORMTEXT    If appropriate, has permission been obtained to contract out these services (see Prior Approval Check List)? If yes, please attach the written approval.  FORMTEXT       Will the proposed contract directly impact any current state personnel system staff? No  FORMCHECKBOX  FORMTEXT    Yes  FORMCHECKBOX  FORMTEXT    If yes, provide the following (attach all supporting documentation). List each employee impacted, the job class, position number, and current salary.  FORMTEXT       What measures will be taken to mitigate the impact, i.e., transfer, training, reassignment of job duties?  FORMTEXT       New position number of job class for impacted employees and new salary (if applicable)?  FORMTEXT       Was an analysis conducted to determine if the service is best performed by filling vacancies or permanently contracting? Provide documentation of the steps taken to address issues with program services before the decision to contract was made, e.g., recruiting efforts, cost benefit analysis.  FORMTEXT       What is the difference in cost between the contractor and the state (supporting documentation must be provided)? Cost must be considered in accordance with Director s Rule 10-2. Contractor Cost State Cost  FORMTEXT        FORMTEXT       Has the individual or contractor performing the service, previously been used in any capacity listed below (indicate type and dates of performance)? No  FORMTEXT     FORMCHECKBOX  Yes  FORMTEXT     FORMCHECKBOX  If yes, give last dates of employment or contract performance. Temporary Employment Dates Permanent Employee Dates  FORMTEXT        FORM9h@ A K L  L N b d f p r v ´´´x`´´K`´)jhv[CJOJQJU^JaJ.jhv[CJOJQJU^JaJmHnHu)jZhv[CJOJQJU^JaJ#jh"kCJOJQJU^JaJ)jhv[CJOJQJU^JaJhv[CJOJQJ^JaJ#jhv[CJOJQJU^JaJhv[CJOJQJ^JaJhv[CJOJQJ^JaJhv[5CJOJQJ^JaJ!89h! 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B D F P R V X زؤؤؤzزؤeؤVؤhv[5CJOJQJ^JaJ)jhv[CJOJQJU^JaJ)jhv[CJOJQJU^JaJ)j'hv[CJOJQJU^JaJhv[CJOJQJ^JaJhv[CJOJQJ^JaJ.jhv[CJOJQJU^JaJmHnHu#jhv[CJOJQJU^JaJ)jhv[CJOJQJU^JaJr t T V X | G??$IfSkd$$Ifl0H$ t644 la $If^$IfSkd$$Ifl0H$ t644 la زؕزrؕ]ؕrؕH)j8hv[CJOJQJU^JaJ)jhv[CJOJQJU^JaJhv[CJOJQJ^JaJ)jhv[CJOJQJU^JaJhv[CJOJQJ^JaJhv[5CJOJQJ^JaJhv[CJOJQJ^JaJ.jhv[CJOJQJU^JaJmHnHu#jhv[CJOJQJU^JaJ)jEhv[CJOJQJU^JaJ  u ^^ & F0`0fkdM$$IflFHP$ t6    44 la$If 2468LNPTV`bvxz~Ⱥȁֺl֨]hv[5CJOJQJ^JaJ)j hv[CJOJQJU^JaJ)jhv[CJOJQJU^JaJhv[hv[CJOJQJ^JaJ#jhv[CJOJQJU^JaJhv[CJOJQJ^JaJhv[CJOJQJ^JaJ#jhv[CJOJQJU^JaJ.jhv[CJOJQJU^JaJmHnHu 2468LNPTV`ززkؤزVؤ)jJ hv[CJOJQJU^JaJ)jhv[CJOJQJU^JaJhv[hv[CJOJQJ^JaJ#jhv[CJOJQJU^JaJhv[CJOJQJ^JaJhv[CJOJQJ^JaJ.jhv[CJOJQJU^JaJmHnHu#jhv[CJOJQJU^JaJ)jvhv[CJOJQJU^JaJ XZ2,. & F0`0^ ^ TT^T & F ^^ & F \ 0`0 @ ^`f   "$.0Z\prtxz­Е€ЕkЕVЕ)j hv[CJOJQJU^JaJ)j hv[CJOJQJU^JaJ)j* hv[CJOJQJU^JaJ.jhv[CJOJQJU^JaJmHnHu)j hv[CJOJQJU^JaJhv[CJOJQJ^JaJ#jhv[CJOJQJU^JaJhv[CJOJQJ^JaJhv[5CJOJQJ^JaJ p(*.ɻɎɀo`ɻKɎɻɻ)j hv[CJOJQJU^JaJhv[5CJOJQJ^JaJ hv[56CJOJQJ^JaJhv[CJOJQJ^JaJ.jhv[CJOJQJU^JaJmHnHu)jt hv[CJOJQJU^JaJhv[CJOJQJ^JaJ#jhv[CJOJQJU^JaJhv[hv[CJOJQJ^JaJ#jhv[CJOJQJU^JaJ ",.JLNPdfhlnx~ز؀kز\؀G؀)j hv[CJOJQJU^JaJhv[5CJOJQJ^JaJ)j hv[CJOJQJU^JaJhv[CJOJQJ^JaJhv[hv[CJOJQJ^JaJ#jhv[CJOJQJU^JaJhv[CJOJQJ^JaJ.jhv[CJOJQJU^JaJmHnHu#jhv[CJOJQJU^JaJ)jH hv[CJOJQJU^JaJpr|~    ^ & F0`0 TT^TT^T & F^ p^|~   !{f)jhv[CJOJQJU^JaJ)jZhv[CJOJQJU^JaJ)j hv[CJOJQJU^JaJhv[CJOJQJ^JaJ.jhv[CJOJQJU^JaJmHnHu)j hv[CJOJQJU^JaJ#jhv[CJOJQJU^JaJhv[CJOJQJ^JaJ# !!B"D"`#b###JJTJVJ~JJJJ$IfK$$If  ^ 4 4^ n^^ & F0`0  ^!!!!!!J"L"`"b"d"h"j"l"n"""""""""""""""""ززؤ}ok}زVؤ}ok})jVhv[CJOJQJU^JaJhv[hv[CJOJQJ^JaJ#jhv[CJOJQJU^JaJ)jhv[CJOJQJU^JaJhv[CJOJQJ^JaJhv[CJOJQJ^JaJ.jhv[CJOJQJU^JaJmHnHu#jhv[CJOJQJU^JaJ)jXhv[CJOJQJU^JaJ""#*#2#B###########$J J JJJJJTJVJXJlJnJpJzJ|JJJJԭ•ԓ~•i•Zhv[5CJOJQJ^JaJ)jhv[CJOJQJU^JaJ)j:hv[CJOJQJU^JaJU.jhv[CJOJQJU^JaJmHnHu)jhv[CJOJQJU^JaJ#jhv[CJOJQJU^JaJhv[CJOJQJ^JaJhv[CJOJQJ^JaJhv[5CJOJQJ^JaJ"TEXT       Contract Performance Dates  FORMTEXT       TO BE SIGNED BY PROGRAM REPRESENTATIVE By signing below, you are certifying that all information, to the best of your knowledge is accurate and true and that the requirements for the business case as outlined in Director s Rules 10-2 have been met. Department/Institution Representative Title Phone Number  THE FOLLOWING TO BE COMPLETED BY HR PERSONNEL ONLY I attest that the acquisition of services from the independent contractor will not result in the separation or displacement of state personnel system staff. Employees directly affected by the contract will be given proper notices as defined in Rule 10-5. Review/Approval Criteria: The following are statutory citations by which the impacts to state personnel system staff are evaluated. Please identify those statutory criteria that would make this request an approvable agreement.   The contract meets the relevant cost savings test. A  Cost Analysis form must be completed and attached to this form. C.R.S. 24-50-503 The contracts is for a new state program (created after 4/7/93), which statutorily authorizes the performance of the program by independent contracts. C.R.S. 24-50-504(2)(b)  The contracted services are not available within the state personnel system, or cannot be performed satisfactorily by state employees, or are of a highly specialized or technical nature. C.R.S. 24-50-504(2)(c) The services are incidental to a contract for the purchase or lease of real or personal property.  C.R.S. 24-50-504(2)(d) The contract is needed to protect against a conflict of interest, or to ensure independent and unbiased findings in cases where there is a clear need for a different, outside perspective. C.R.S. 24-50-504(2)(e)  The contractor will provide equipment, materials, facilities, or support services that could not feasibly by provided by the state in the location where the services are to be performed. C.R.S. 24-50-504(2)(f)  The contractor will conduct training courses for which appropriately qualified state personnel system instructors are not available. C.R.S. 24-50-504(2)(g)  The services are of an urgent, temporary, or occasional nature. C.R.S. 24-50-504(2)(h) The contract is for purchased services. (The acquisition of services which directly benefit specific groups or individuals in the public at large.) C.R.S. 24-50-504(3)  This is an intergovernmental agreement. C.R.S. 24-50-508 The services provided are for a term of six months or less and are not expected to recur on a regular basis. C.R.S. 24-50-513 PERSONAL SERVICES CERTIFICATION HR Representative ONLY Independent Contractor Certification: The signature below indicates that the contract or commitment voucher is indeed an independent contract that does not create an employee-employer relationship and that these documents contain the required independent contractor language as part of the Director s Rules 10-4(E)(4). Department/Institution Certification: I hereby certify that the attached agreement for personal services meets at least one criterion stated above and that all responses on this certification are true and accurate, to the best of my knowledge. 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L^`LhH. jUZVY#A%^{^LAAb]'oBYKy#2+\ ,                 H        ,                           C       ,        v["kNl%89#UV1xy"@ MRHt MMMMMMMMMMM M M M M MP@P P PPPPPPPPPP P"PJUnknownGz Times New Roman5Symbol3& z Arial7&  Verdana5& zaTahoma;Wingdings?5 z Courier New"1hzzCܙFu2u2!84d3QHX ?v[2 OFFICIAL COLORADO STATE DOCUMENTTTTvgraves8         Oh+'0 , L X d p|$OFFICIAL COLORADO STATE DOCUMENTTTT Normal.dotvgraves2Microsoft Office Word@F#@@눦@눦u՜.+,04 hp  0Department of Health Care Policy and Financing2 !OFFICIAL COLORADO STATE DOCUMENT Title  !"#$%&'()*+,-./0123456789:;<=>?@ABDEFGHIJKLMNPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F&Data CU1TableOp^WordDocumentzSummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q