HomeMy WebLinkAbout2013-087 Aging - NC Department of Health and Human Services for Caregiver Support $25,000 Please return this copy to 4 9.. ,V4
—Clerk to the Board's office for PAF Contract Number 00028582/Page 1 of49
GENERAL CONTRACT COVER
This contract is hereby entered into by and between the North Carolina Department of Health and
Human Services, Division of Aging and Adult Services (the"Division")and Orange.County(the
"Contractor") (referred to collectively as the"Parties").
1. Contract Documents:
This contract consists of the following documents,which are incorporated herein by reference:
(a) This contract cover
(b) The General Terms and Conditions
(c) Scope of Work
(d) Performance Measures Chart
(e) The Line Item Budget
(f) State Certification
Incorporated By Reference
The following documents are reference materials and are available by going to the following
website, Open Window
(http://dhhsopenwindow.nc.-gov/index.aspx?pid=doc ReferenceDocuments).
(a) Executive Order No. 24
(b) Travel: Policies Governing Travel Related Expenses for Contractors
(c) General Statutes G.S.143C6 NonState Entities Receiving State Funds
(d) Subchapter 03M Uniform Administration of State Grants
These documents constitute the entire agreement between the Parties and supersede all prior
oral or written statements or agreements.
2. Precedence Among Contract Documents:
In the event of a conflict between or among the terms of the Contract Documents, the terms in the
Contract Document with the highest relative precedence shall prevail. The order of precedence
shall be the order of documents as listed in the contract document section, with the first-listed
document having the highest precedence and the last-listed document having the lowest
precedence. If there are multiple contract amendments, the most recent amendment shall have
the highest precedence and the oldest amendment shall have the lowest precedence.
3. Effective Period:
This contract shall be effective on 3/22/2013 and shall terminate on 3/21/2014,with the option to
extend, if mutually agreed upon, through a written amendment as provided for in the General
Terms and Conditions.
4. Contractor's Duties:
The Contractor shall provide the services as described in the scope of work and in accordance
with the approved budget.
5. Division's Duties:
The Division shall pay the Contractor in the manner and in the amounts specified in the contract
documents. The total amount paid by the Division to the Contractor under this contract shall not
exceed $25,000. This amount consists of$25,000 in State funds, $0 in Local funds, $0 in Other
funds and$0 in Federal funds.
The total contract amount is$25,000.
NCDHHS GCT1007(Contract) (General) (Rev. 9/12)
Contract Number 000285821 Page 2 of 19
6. Conflict of Interest Policy:
The division has determined that this contract is not subject to N.C.G.S. 143C-6-22&23.
7. Reversion of Unexpended Funds:
Any unexpended grant funds shall revert to the Division upon termination of this contract.
8. Grants:
The Contractor/Grantee has the responsibility to ensure that all sub-grantees, if any, provide all
information necessary to permit the Contractor/Grantee to comply with the standards set forth in
this contract:
9. Reporting Requirements:
The Division has determined that this is a contract for financial assistance with a Public Entity.
Local governmental agencies subject to N.C.G.S. § 159-34, annual independent audit; rules and
regulations, OMB Circular A-133,Audits of States, Local.Governments, and Non-Profit
Organizations, and N.C.G.S. § 143C-6-22, use of state funds by non state entities. If subgranting
is allowable, a nongovernmental subgrantee is subject to the reporting requirements described on
the Notice of Certain Reporting and Audit Requirements. Regulations and Reporting
Requirements of N.C. General Statute 143C-6.23 can be found at ncgrants.gov.
10. Payment Provisions:
Upon execution of this contract, the Contractor shall submit to the Division Contract
Administrator, a monthly reimbursement request for services rendered the previous month by the
10th of each month and, upon approval by the Division, receive payment within 30 days. Monthly
payment shall be made based on actual expenditures made in accordance with the approved
budget on file with both parties and reported on the monthly expenditure report submitted by the
Contractor. If this contract is terminated, the Contractor shall complete a final accounting report
and return any unearned funds to the Division within 30 days of the contract termination date. The
Division shall have no obligation for payments based on expenditure reports submitted later than
30 days after termination or expiration of the contract period.All payments are contingent upon
fund availability.
11. Contract Administrators:
All notices permitted or required to be given by one Party to the other and all questions about the
contract from one Party to the other shall be addressed and delivered to the other Party's contract
administrator.The name, post office address, street address, telephone number, fax number, and
email address of the Parties' respective initial contract administrators are set out below. Either
Party may change the name, post office address, street address, telephone number, fax number,
or email address of its contract administrator by giving timely written notice to the other Party.
NCDHHS GCT1007(Contract) (General) (Rev. 9/12)
Contract Number 00028582/Page 3 of 19
For the Division:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Alicia Blater Alicia Blater
Division of Aging and Adult Services Division of Aging and Adult Services
2101 Mail Service Center 2101 Mail Service Center
Raleigh, NC 27699-2101 Raleigh, NC 27699-2101
Telephone : (919)-855-3413
Fax: O--
Email: alicia.blater@dhhs.nc.gov
For the Contractor:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Mary Fraser,Aging Transitions Unit Mary Fraser,Aging Transitions Unit
Administrator Administrator
Orange County Orange County
2551 Homestead Rd. 2551 Homestead Rd.
Chapel Hill, NC 27516 Chapel Hill, NC 27516
Telephone: (919)-245-4276
Fax: (919)-968-2093
Email: mfraser oran ecount nc. ov
12. Supplementation of Expenditure of Public Funds:
The Contractor assures that funds received pursuant to this contract shall be used only to
supplement, not to supplant,the total amount of federal, state and local public funds that the
Contractor otherwise expends for contract services and related programs. Funds received under
this contract shall be used to provide additional public funding for such services;the funds shall
not be used to reduce the Contractor's total expenditure of other public funds for such services.
13. Disbursements:
As a condition of this contract, the Contractor acknowledges and agrees to make disbursements
in accordance with the following requirements:
(a) Implement adequate internal controls over disbursements;
(b) Pre-audit all vouchers presented for payment to determine:
• Validity and accuracy of payment
• Payment due date"
• Adequacy of documentation supporting payment
• Legality of disbursement
(c) Assure adequate control of signature stamps/plates;
(d) Assure adequate control of negotiable instruments; and
(e) Implement procedures to insure that account balance is solvent and reconcile the account
monthly.
14. Outsourcing to Other Countries:
The Contractor certifies that it has identified to the Division all jobs related to the contract that
have been outsourced to other countries,if any. The Contractor further agrees that it will not
outsource any such jobs during the term of this contract without providing notice to the Division.
15. Signature Warranty:
NCDHHS GCT1007 (Contract) (General) (Rev. 9/12)
Contract Number 00028582/Page 4 of 19
The undersigned represent and warrant that they are authorized to bind their principals to the
terms of this agreement.
Signatures follow on next page
NCDHHS GCT1007(Contract) (General) (Rev. 9/12)
Contract Number 00028582!Page a of 19
In Witness Whereof, the Contractor and the Division have executed this contract in duplicate originals,with
one original being retained by each party.
Orange Coun
Sign Date
Frank Clifton County Manager
Printed Name Title
WITNESS
— &"b� 3 1.2 3
Signature Date
Printed—Name Title
Division of Aging and Adult Services, North Carolina Department of Health and Human Services
Signature Date��
Dennis Streets Director
Printed Name Title
NCDHHS GCT1007(Contract) (General) (Rev. 9112)
.This instrument has been approved as to technical content.
J jceTyler, Departmen irector
This instrument has been pre-audited in the manner.required by the Local Government Budget and
Fiscal Control Act.
Office of the Finance Director
This instrum t has a roved as to form and legal sufficiency.
Offi.0 of the Cou orney
Contract Number 0OO285B2/Page Gof19
GENERAL TERMS AND CONDITIONS
Relationships of the Parties Indemnification: The Contractor agrees ho nify
and hold harmless the Division, the State of North
Independent Contractor: The Contractor ioand mhoU CanoUno, and any of their officers, agents and
be deemed to be an independent contractor in the employees, from any claims of third parties arising out of
performance of this contract and oe such shall bowholly any act or omission of the Contractor in connection with
responsible for the work to be padbmmmd and for the the performance of this contract to the extent permitted
supervision of its employees. The Contractor represents by law.
that it hoo, or shall secure at its own expense, all
personnel required in performing the services under this Default and Term/notion
agreement. Such employees shall not be employees of,
or have any individual contractual relationship with, the Termination Without Cause: The Division may
Division. tenninsdethks contract without cause by giving 30 days
written notice to the Contractor.
Subcontracting: The Contractor shall not subcontract '
any of the work contemplated under this contract without Termination for Cause: |f, through any causa, the
prior written approval from the Division. Any approved Contractor shall fail to fulfill its obligations under this
subcontract shall be subject to all conditions of this contract ino timely and proper manner, the Division shall
contract. Only the subcontractors specified in the have the right bo terminate this contract by giving written
contract documents are tobm considered approved upon notice bo the Contractor and specifying the effective date
cmvond of the contract. The Division ohoU not be thenaPf. In that ovent, all finished or unfinished
obligated to pay for any work performed by any deliverable items prepared by the Contractor under this
unapproved subcontractor. The Contractor shall be contract ohaU, at the option of the Divioion, become its
responsible for the performance of all of its property and the Contractor shall be entitled to receive
subcontractors. just and equitable compensation for any satisfactory
work completed on such meberia|a, minus any p t
Assignment: No assignment of the Contractor's or compensation previously mode. Notwithstanding the
obligations or the Contractor's right to receive payment foregoing provision, the Contractor shall not be relieved
hereunder shall be permitted. Howevor, upon written of liability to the Division for damages sustained by the
request approved by the issuing purchasing authnrity. Division by virtue of the Contractor's breach of this
the State may: agreement, and the Division may withhold any payment
(s) Forward the Contractor's payment check(s) due the Contractor for the purpose of setoff until such
directly hu any person or entity designated bythe time aa the exact amount of damages due the Division
Contnyctor, or from such breach can bedetennined. In case ofdefault
(b) Include any person or entity designated by by the Contractor,without limiting any other remedies for
Contractor as a joint payee on the Contractor's breach available to it. the Div iokzn may procure the
poymantchack(a). contract services from other sources and hold the
in no event shall such approval and action obligate the Contractor responsible for any excess cost occasioned
State to anyone other than the Contractor and the thereby. The filing of petition for bankruptcy by the
Contractor shall remain responsible for fulfillment #fall Contractor shall beon act of default under this contract.
contract obligations.
Waiver ofDefault: Waiver bythe Division nf,anydefaub
Beneficiaries: Except as herein specifically provided or breach in compliance with the terms of this contract
othonwioo, this contract ohoU inure bothe benefit ofand by the Contractor shall not be deemed o waiver ofany
be binding upon the parties hereto and their respective subsequent default urbreach and oheU not be construed
successors. It is expressly understood and agreed that to be modification of the banns of this contract unless
the enforcement of the terms and conditions of this abubad to be such in vvhting, signed by an authorized
oontmact, and all rights of action relating to such representative of the Department and the Contractor and
anfon:emont, oho|| be strictly reserved to the Division attached bo the contract.
and the named Contractor. Nothing contained in this
document shall give or allow any claim or right ofaction Availability of Funds: The parties to this contract
whatsoever by any other third person. It is the express agree and understand that the payment of the sumo
intention of the Division and Contractor that any such specified in this contract is dependent and contingent
person or entity, other than the Division or the upon and subject hothe approphadon, allocation, and
Contnaohor, receiving services orbenafiha under this availability of funds for this purpose to the Division.
contract shall be deemed on incidental bsmafioiaryonly.
FmrceNYojeomm: Neither party shall be deemed tobein
Indemnity and Insurance default of its obligations hereunder if and ap long asitia
prevented from performing such obligations by any act of
vvor, hostile foreign ocdon, nuclear explosion, hot.
NCOHHGTC1O1O (General Terms and Conditions)(Local Government)(Rav 11.15.12)
. .
� Contract Number DO[28582/Page 7of19
strikes, civil insurrection, earthquake, hurricane, tomado, Oversight
or other catastrophic natural event or act ofGod.
Access to Pmnawmm and Records: The State Auditor
Survival of Promises: All pnomiseo, naquinaments, shall have aouama to persons and records as o result of
bannw, conditiona, pnovisiono, nepnaaenbationo, all contracts or grants entered into by Gbsby agencies or
guonantaey, and warranties contained herein ahoU political subdivisions in accordance with General Statute
survive the contract expiration or termination date unless 147-64.7. Additiona|hy, as the State funding authority,
specifically provided otherwise henain, or unless the Department of Health and Human Services aho||
superseded by applicable Federal or State statutes of have eoceme to persons and records as o result of all
{imitation. contracts or grants entered into by State agencies or
political subdivisions.
Intellectual Property Rights '
Record Retention: Records shall not be deotroyed.
Copyrights and Ownership of Deliverables: All purged or disposed of without the axpxaom written
deliverable items produced pursuant to this contract are consent of the Division. State bonk: naoonJo retention
the exclusive property of the Division. The Contractor policy requires all grant records to be retained for o
shall not assert a claim of copyright or other property minimum of five years or until all audit exceptions have
interest in such deliverables. been reoo|ved, whichever is longer. If the contract is
subject to Federal policy and regulations, nsnpmd
Compliance with Applicable Laws retention may be longer than five years since records
must be retained for a period of three years following
Compliance with Lmmvm: The Contractor shall comply submission of the final Federal Financial Status Report,
with all |ame, ordinancao, codes, ru|es, nagu|etions, and if applicable, or three years following the submission ofa
licensing requirements that are applicable bo the conduct revised final Federal Financial Status Report. A|so, if
of its businesa, including those of federal, stote, and any |Uigotion, o|airn, negotiatiun, audit, diaa|kmvonoe
local agencies having jurisdiction and/or authority. action, or other action involving this Contract has been
started before expiration mf the| rnsbertionpehod
Equal Employment Opportunity: The Contractor shall described obovo, the records must be retained until
comply with all federal and State laws relating to equal completion of the action and resolution of all issues
employment opportunity. which ohoe from it, or until the end of the regular five-
year period daonhhed oboma. whichever is later. The
Health Insurance Portability and Accountability Act record retention period for Temporary Assistance for
(HUPAA): The Contractor agrees that, if the Division Needy Families (TANF) and MEDICAID and Medical
determines that some or all of the activities within the Assistance grants and programs must be retained for a
scope of this contract are subject to the Health minimum of ten years.
Insurance Portability and Accountability Act of1B86. P.L _
1Q4-S1. oa amended ("H|P/A ). or its implementing Miscellaneous
regu|etiono, it will comply with the H|PAA requirements
and will execute such agreements and practices aethe Choice mfLaw: The validity of this contract and any of
Division may require bo ensure compliance. its terms or provisions, as well os the rights and duties of
the parties to this contract, are governed by the \ewo of
Executive Order # 24: It is unlawful for any vendor. North Carolina. The Contractor, by signing this contract,
contractor, subcontractor or supplier of the state tomake agrees and submits, solely for matters concerning this
gifts or to give favors to any state employee. For Contract, to the exclusive jurisdiction of the courts of
additional information regarding the specific ,North Carolina and agrees, solely for such purpose, that
naquinamnanba and azamptiono, contractors are the exclusive venue for any legal proceedings shall be
encouraged to review Executive Order 24 and Q.S. Sec. Wake County, North Carolina. The place of this contract
133-32. and all transactions and agreements relating to it. and
their situs and forurn, shall be Wake Connty, North
Confidentiality Cano|ine, where all mattemu, whether sounding in
contract or tort, na|eding to the validity, construction,
Confidentiality: Any infonnstion, dsda, inotmumento, inb*rppabation, and enforcement shall be determined.
documente, studies or reports given to or prepared or
assembled by the Contractor under this agreement shall Amendment: This contract may not be amended orally
be kept as confidential and not divulged or made orbyperformance. Any amendment must bm made in
available to any individual or organization without the written form and executed by duly authorized
prior written approval of the Division. The Contractor representatives of the Division and the Contractor. The
acknowledges that in receiving, storing, i r Punohaoeond'Contnact Divisions uf the NC Department
otherwise dealing with any confidential information it will of Administration,and the NC Department of Health and
safeguard and not further disclose the information Human Services shall give prior approval to any
except aa otherwise provided in this contract. amendment tmo contract awarded through those offices.
NCOHHSTC10i0 (General Terms and Conditions) (Local Government) (ReV 11.15.12)
����-
Contract Number OOd28582/Page qof1A
' property furnished to it for use in connection with the
SeverabiUity: \n the event that a court ofcompetent of this contract and will reimburse the
jurisdiction holds that a provision or requirement of this Division for loss of, ur damage to, such property. At the
contract violates any applicable law, each such provision termination of this contract, the Contractor shall contact
or requirement shall continue. to be enforced to the the Division for instructions ambo the disposition ofsuch
extent it is not in violation of law or is not otherwise property and shall comply with these instructions.
unenforceable and all other provisions and requirements
of this contract shall remain in full force and effect. Travel Expenses: Reimbursement to the Contractor for
travel mileage, meals, lodging and other travel expenses
Headings: The Section and Paragraph headings in incurred in the performance of this contract shall not
these General Terms and Conditions are not material exceed the rates published in the applicable State rules
poda of the agreement and should not be used to or approved local government travel policy. International
construe the meaning thereof. travel shall not be reimbursed under this contract.
Time of the Essence: Time is of the essence in the Sa|ea/UmaTax Refunds: |f eligible, the Contractor and
performance of this contract. all subcontractors shall: (o) ash the North Carolina
Department of Revenue for a refund cf all sales and use
Key Personnel: The Contractor shall not nap|auo any of taxes paid by them in the performance of this oontract,
the key personnel assigned to the performance of this pursuant to G.S. 106-164.14; and (b) exclude all
contract without the prior written approval of the Division. refundable sales and use taxes from all reportable
The term "key personnel" includes any and all persons expenditures before the expenses are entered in their
identified as such in the contract documents and any reimbursement reports.
other persons subsequently identified as hey personnel
by the written agreement of the parties. Advertising: The Contractor shall not use the award cf
this oordnyc± as a pad of any news release or
Care ofProperty: The Contractor agrees that it shall be commercial advertising.
responsible for the proper custody and care of any
NCOHH8TC1O1O (General Terms and (Local Government) (Ray. 11j5.12)
Contract Number 000285821 Page 9 of 19
SCOPE OF WORK
BACKGROUND
North Carolina's 65 and older population will almost double in the next 20
years from 1.3 to 2.3 million by 2013. This aging population along with
adults who have special needs has increased caregiving among family and
friends.
Caregivers provide support and ongoing care for an individual with special
needs, or who may be at risk of abuse or neglect. Statewide, nearly 20% of
respondents to the NC State Ceder for Health Statistics reported providing
caregiving services. Caregivers often receive little training to
provide services and are not aware of the level of care and the available
resources to support their unpaid work. Further, caregiving supports for
individuals who transition from facilities to their homes are vital to enable
those individuals to remain in their homes. Caregivers have been shown to
benefit from a network of support or respite services to provide temporary
relief for family caregivers from the ongoing responsibility of caring.
NC is currently one of 30 states that received funding to encourage states to
focus on caregiver services, strengthen a state's collaboration and
infrastructure for respite, and assist where possible in a coordinated system
of accessible, community-based respite care services for family caregivers of
children or adults of all ages with special needs. The Lifespan Respite
Project activities are ongoing and are led by the Division of Aging and Adult
Services, in partnership with several divisions and organizations within the
public and private sectors.
This Family Caregiver-to-Caregiver Peer Support initiative, funded by Money
Follows the Person rebalancing dollars, will strenghthen North Carolina's
respite and caregiver support system by developing a replicable model of
family caregiver to caregiver peer support.
Family Caregiver-to-Caregiver Peer Support is provided by a person who
has self-identified as a current or past caregiver of a special needs child,
adult or elder and who has successfully navigated community-based
services to access resources necessary to build resiliency and foster
wellbeing in the home, school, and community. This individual must receive
training to enhance or support their knowledge of caregiver issues and
community resources. Furthermore, they must beltrained in person-centered
care and foundational communication principles, including active listening
skills, goal setting and crisis intervention.
Money follows the Person is a federal and state demonstration project that
assists Medicaid-eligible North Carolinians who live in qualified inpatient
facilities to move into their own homes and communities with supports.
Scope of Work(Rev.4/12)
Contract Number 000285821 Page 10 of 19
Leadership from the Division of Medical Assistance (DMA) Money Follows
the Person Project are actively involved with the NC Lifespan Respite
Project. Previous surveys had identified the greatest barriers to successfully
transitioning from an institution to community living to be limited housing
supports and limited caregiver supports. This identified need led to the
development of a competitive grant opportunity to eligible organizations
across the state in collaboration with the Division of Medical Assistance
(DMA) through the Lifespan Respite Care and Money Follows the Person
Projects.
Chinese-Americans are the largest sub-group of Asian-Americans and the
second largest immigrant group in the U.S., after Mexican Americans. North
Carolina is expected to see a rapid increase in older Chinese immigrants
over the next decades. NC is already one of the top five states in the growth
of the Asian-American population. Between 2000 and 2010, NC saw the
proportion of the state's Asian-American population grow by 85 percent.
Asian-Americans and immigrants are the largest minority group in the
Chapel Hill/Carrboro metropolitan area.
This contract was awarded through a Request for Application (RFA).
Applicants were asked to propose projects designed to meet community
needs.
PURPOSE
This contract supports a pilot program to implement a family caregiver-to-
caregiver support model, targeting families who have recently assumed
more caregiving responsibilities for an individual transitioning back to their
home/community or individuals that are at risk of being admitted into a long-
term care facility.
SCOPE OF WORK(PERFORMANCE REQUIREMENTS)
The contractor will operate a "family caregiver-to-caregiver support" project
in Orange County, North Carolina. The program will recruit at least 15
Asian-American volunteers per year tb serve as family caregiver to caregiver
supporters. The majority of volunteers trained will be Chinese-speaking.
The contractor will provide training that includes the following elements:
Being a family caregiver"peer" and gaining insight from existing
peer support models.
Sharing public and community resources available to support the
family caregiver and care recipient, particularly respite care
Scope of Work(Rev. 4/12)
Contract Number 00028582/Page 14 of 19
services.
Being trained in person-centered planning.
Having the commitment to assist family caregivers in developing a
plan that outlines: how caregiver will take care of self; support
schedules, crisis planning; other support options.
Calling, visiting, and being available to offer support and guidance
as the family caregiver needs it, including hours outside of the
normal business day.
PERFORMANCE STANDARDS
Qualifications for peer support volunteers in this demonstration include ability
to speak Chinese (bi-lingual), experience as a caregiver, and a desire to
support other caregivers of at-risk older adults.
Orange County Department on Aging's (OCDOA) Project Coordinator and
volunteers selected for this demonstration, will participate in the Person
Centered Thinking curriculum offered by the UNC School of Social Work.
OCDOA will forma Project Advisory Committee. This committee will include
representatives from key area Chinese-American and Asian-American
societies and associations.
OCDOA will develop English and Mandarin project training and outreach
materials.
Volunteers will participate in peer supervision meetings at least monthly.
The Project Coordinator and volunteers will rely on "The Alzheimer's
Association Toolkit Serving Asian and Pacific Islander Families: Home and
Community Based Services for People with Dementia and their Caregivers"
as awareness building materials and foundation for their demonstrated peer
coaching model of caregiver support.
PERFORMANCE MONITORING/QUALITY ASSURANCE PLAN
OCDOA will submit completed Quarterly Reports to the Division. OCDOA
will work with the Division to establish due dates for quarterly reports.
Quarterly Reports will capture numbers of volunteers trained, numbers of
volunteer hours provided, numbers of caregivers served, community
outreach activities, activities of Project Advisory Committee, project
successes and challenges, and impact of project on overall contribution to
Chinese-language caregiver support resources and community-based
services in Orange County.
OCDOA will also survey the members of the Project Advisory Committee
and the caregivers who have received services from a volunteer peer prior to
the conclusion of this initial year to better evaluate the demonstration's
Scope of Work(Rev. 4112)
Contract Number 000285821 Page 12 of 19
impact and suggestions for modifications for year two of the demonstration_
REIMBURSEMENTS
OCDOA will be reimbursed for approved expenses outlined in their project
budget. OCDOA will submit a monthly reimbursement form to the
Division itemizing category expenses.
Scope of Work(Rev. 4/12)
Contract Number 00028582/Page 13 of 19
PERFORMANCE MEASURES CHART
The Department of Health and Human Services uses performance measures rubrics as a tool to
determine the success of a project and how well services and products are being delivered.
Together they enable the Department to gauge efficiency, determine progress toward desired
results and assess whether the Department is on track with meeting its goals. The contractor
shall adhere to all of the performance requirements/standards in the scope of work, including
performance measures in the performance measures chart below.
Output Annual
Products/materials available for replication for use with other Chinese-speaking
populations
1 Increase
2
Vendor Products
Vendor Product
Annually
Outcome Quarterly
Number of caregivers served by peer volunteers
1 Increase
15
Vendor Reports
Vendor Reports
Annually
Outcome Annual
JImpact iver peer volunteer on caregiver stress/burden
7 1 Other
Increase in respondants who experience less stress in caregiving
Performance Measures (Rev.4//12)
Contract Number 00028582 J Page 14 of 19
Caregiver Surveys
Vendor Reports
Annually
Performance Measures (Rev..4//12)
Contract Number 00028582/Page 15 of 19
LINE ITEM BUDGET
This begins.the line item budget for year 1
$0.00
Salary\Wages Project Coordinator will complete tasks related to volunteer $18,074.00
recruitment,training, support, and evaluation.
Fringe Benefits $2,228.00
Other $0.00
Repair and Maintenance $0.00
Staff Development $0.00
Dues and Subscriptions $0.00
Subcontracts and Grants $0.00
I
Match $0.00
Line Item Budget Detail(08/11)
Contract Number 00028582/Page 16 of 19
Cost Per Service $0.00
Supplies and Materials Other Cell phone $420.00
Supplies and Materials Other Educational material and supplies $100.00
Supplies and Materials Other Volunteer recruitment, program outreach $1,000.00
Supplies and Materials Other Volunteer Training, Person-Centered Thinking Training $990.00
Equipment IT Computer expenses $1,814.00
Travel Contractor Staff Volunteer staff mileage $374.00
$25,000.00
Indirect Cost $0.00
$25,000.00
Line Item Budget Detail (08/11)
I i
f
Contract Number 000 !85821
page 17 of?9
s
$a.00
Pr--LfVolu $0.00
ntee
r
Coordinator
$18,074. 0
0.0000
12 100.00 J
°10 $2.228.00
$6.00
$2p,302.00
Line Item Budget Detail(D8/
11)
State Certification Contract Number 00028582/Page-1 8 of 19
Contractor Certifications Required by North Carolina Law
Instructions
The person who signs this document should read the text of the statutes cited herein and consult with counsel
and other knowledgeable persons before signing. The text of G.S. 143-59.1 can be found online at:
http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter 143/GS 143-59.1.pdf
The text of G.S. 143-59.2 can be found online at:
hU://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/B-ySecfon/Chapter 143/GS 143-59.2.1)
The text of G.S. 105-164.8(b)can be found online at:
htip://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDFBySection/ChVter 109GS 105-164.8.pdf
Certifications
(1) Pursuant to G.S. 143-59.1(b), the undersigned hereby certifies that the Contractor named below is not
an"ineligible Contractor"as set forth in G.S. 143-59.1(a)because:
(a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under
Article 5 of Chapter 105 of the General Statutes on its sales delivered to North Carolina when the
sales met one or more of the conditions of G.S. 105-164.8(b); and
(b) [check one of the following boxes]
® Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a "tax
haven country" as set forth in G.S. 143-59.1(c)(2) after December 31,2001; or
❑ The Contractor or one of its affiliates has incorporated or reincorporated in a"tax haven
country" as set forth in G.S. 143-59.1(c)(2) after December 31, 2001 but the United
States is not the principal market for the public trading of the stock of the corporation
incorporated in the tax haven country.
(2) Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractor's officers,
directors, or owners (if the Contractor is an unincorporated business entity) has been convicted of any
violation of Chapter 78A of the General Statutes or the Securities Act of 1933 or the Securities
Exchange Act of 1934 within 10 years immediately prior to the date of the bid solicitation.
(3) The Contractor shall require its subcontractors, if any, to make the same certifications before they
perform any work under the contract.
(4) The undersigned hereby certifies further that:
(a) He or she is a duly authorized representative of the Contractor named below;
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(b) He or she is authorized to make, and does hereby make, theQb@bV ►i�o*mffXM?6MZjiFh*jAW 19
the Contractor; and
(c) He or she understands that any person who knowingly submits a false certification shall be guilty
of a Class I felony.
Orange County Department on Aging
Contractor's Name
Si a e of Contractor's Aighorized Agent Date
Printed Name of Contr or's Authorized Agent Title
1161 ,
Signature of Witne s Title
Printed Name 6f Witness Date -
The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date this document
immediately thereafter.
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