[VENDOR NAME]

Statement of Work #

This Statement of Work (“SOW”) is made pursuant to the Master Services Agreement, dated as of ______, 20__ between NYU Hospitals Center (“NYUHC”) and [Include Vendor] ______(the “Agreement”), and, accordingly, is subject to and hereby incorporates by reference the terms and conditions set forth therein. The Effective Date shall be based upon the last person signing.

1.  Project Name:

2.  Type of Project (place an ‘X’ in appropriate column):

Fixed Cost / Time & Material

3.  Description of Services (please provide as much detail as possible, including project milestones):

4.  Costs of Services/Deliverables (use table below, or describe in equal or greater detail):

Type of Labor /Deliverable
(add as needed) / # of Hours or Deliverables
(if applicable) / Hourly or Deliverable Rate
(if applicable) / Cost
Travel Costs
Total Cost

5.  EXPENSES. – Expenses need to be pre-approved in writing or email and must adhere to the NYUHC Travel & Expense Policy,

6.  Project Schedule:

Estimated Start Date / Estimated End Date

7.  Will the person be on-site? If so please state the building and floor

(if they are not full time on site please provide the additional information to help with space planning)

Will the person be in a patient area? If so additional medical testing is required.

8.  Vendor Project Manager or Contact:

Name:

Address:

Email:

Phone #:

Cell #:

9.  Approval. No Deliverable shall be deemed delivered until it has been approved in writing by NYU HOSPITALS CENTER.

10.  Reporting. The Consultant will submit written reports to NYU HOSPITALS CENTER on a weekly basis to [______] ([) or his/her nominee.

11.  Personnel of Consultant. The following personnel will provide the Services:

Resource Title / Time/Hrs / Responsibility

IN WITNESS WHEREOF, the parties have caused this Statement of Work to be executed by their duly authorized representatives on the date(s) shown below.

NYU Hospitals Center: Vendor :

______

Signature Signature

______

Name (print or type) Name (print or type)

______

Title Title

______

Date Date

Taxpayer ID#:______

Rev. 6-2016