Contractor Requisition Form – Burrell College of Osteopathic Medicine Forms

Department Information:

Department Chair/Head Name:

First Last

Title:

Department:

Line Item Number from which compensation will be paid from:*

Contractor Information:

For which campus will the contractor primarily work?*

Name:

First Last

Title:

Start Date:

End Date:

Proposed Compensation Rate:

Choose one and enter estimated amount

Physician/PhD Hourly Rate
Salary $______ (for a longer-term contract)
One-time payment $ _______ (for an honorarium, one-time fee, etc.)
Other Hourly Rate

Amount:

Frequency of Compensation:

One Time
Reoccurring

Estimated hours:

Choose one & enter estimate hours

Hours Total
Hours Per Week
Hours Per Month

Estimated Hours Amount:

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Is this Contractor for the Clinical Medicine Department?*

Yes
No

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Do we already have a faculty member at Burrell that can teach this content?*

Yes
No

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Is there space in the budget for this contractor?*

Yes
No

Enter a short description of work requested of contractor:*

(i.e. sessions to be taught, special directions for contract, etc.)

Items to be attached: CV/Resume*

Drop files here or

Accepted file types: pdf, doc, docx, gif, png, jpg, Max. file size: 8 MB.

Items to be attached: Transcripts – if requesting a faculty appointment for a non-physician.

Drop files here or

Accepted file types: pdf, doc, docx, gif, png, jpg, Max. file size: 8 MB.

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Justification for Contractor:*

(i.e. Do we have someone at Burrell that can teach this session?)

Request Faculty Appointment:

Check if requesting faculty appointment for guest lecturer

Elevated IT Access:

No extra resources needed
Yes – IT resources requested

Please select IT Resources needed:

LEO/Panapto
Zoom
Burrell Email
Library Access
Lecture Hall Drive
Building Key Card
Equipment
Other

Additional Information (optional):

Additional Files (optional):

Drop files here or

Accepted file types: jpg, pdf, png, doc, docx, gif, Max. file size: 8 MB.