Cost Benefit Analysis Form

(Explain why this contract is necessary, cite laws or regulations, explain reasonableness of cost, and explain why work cannot be accomplished by another state employee or another state agency.) Is this contract with a current or retired state employee: Yes No (If yes, attach a statement to substantiate reason for this employment.) () Contract Monitor Phone Number Date Is there any relationship or association between the contractor and employees of this facility which is prohibited by the code of ethics or which could give the appearance of affecting the judgment of employees of your office in negotiating, monitoring, or paying for the contracted services Yes No If so, what measures have been undertaken to remedy this situation How long has the contractor been providing these services to the hospital Has the contract been automatically renewed for a number of years How many years Do you anticipate contracting with this provider in the future What is this contractor s history of performance as reflected in prior monitoring reports List other contracts this provider has with your facility: (ATTACH A SEPARATE PAGE IF NEEDED) CFMS HCSD AMOUNT SERVICE PROVIDED CFMS HCSD AMOUNT SERVICE PROVIDED CFMS HCSD AMOUNT SERVICE PROVIDED LSU-HCSD CONTRACT COORDINATOR COMMENTS: LSU-HCSD HOSPITAL ADMINISTRATOR/COO COMMENTS: LSU-HCSD CONTRACT ADMINISTRATOR COMMENTS:.