HomeMy WebLinkAboutR 2013-266 Health - Piedmont Health Services for PHS and OCHD agree for certification of WIC clients at OCHD ►-ate
ORANGE COUNTY-CONTRACT CONTROL SHEET
rder: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services, (5)Attorney,(6)Manager,(7)Clerk
hall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager
ntract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for
nust be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should
be completed through the legal review process prior to being routed for signature.
Department
Party/Vendor Name: Piedmont Health Services Party/Vendor Contact Person: Brian Toomey Contact Phone: 919-933-8494
Party/Vendor Address:229 Lloyd Street City Carrboro State: NC Zip: 27510 Department: Public Health Amount:N/A Purpose:PHS
and OCHD agree for certification of WIC clients at OCHD Budget Code(s): Vendor 9 27898 (N/A if new vendor) Vendor is a
BOCC consultant? Yes❑No® Contract Type: (Check one)New® Renewal ❑ Amendment ❑ Effective Date July 1,2013
Approved by Board Yes[]No[] Agenda Date: Title of Contract: Piedmont Health Services WIC Program
If this is a Grant Agreement, pre-application has been approved by the Board of Commissioners Yes❑No[]. If submitted for bid were
bids/RFPs received Yes❑No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content:
1
Department Director's Signature: Date: " .-Q 4
IT Director
(Applicable only to hardW0r 4 are urchases or related services)This contract has b �dpproved by the Information
Technology Director as to technical content an mation t eci ications:
IT Director's Sign; Da e.
Risk Management
Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance Required 2• Hold
Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,this contract is approved
by the Risk Manager:
Risk Manager's Signature: ,�' D 7
ate:
Financial Services
This Contract is conditioned u n appropriation by the Board of Commissioners Yes❑No� A budget amendment is necessary
before approval Yes❑No�f budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the
manner required by the Local Government Bud t /n+d Fisc?-1 Control Act-
Financial Services Director's Signature: X(t yC�---w �• Date:
County Attorney
Approval by Board ❑ (Contracts $90,00 r more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approval by Manager ] 1 Lost other contracts$1,000 and above). Department Director approval only '(Under
$1,000). This contract has b revi ed and approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date: Z� 3
County Manager
This contract has been reviewed and is approved by the County Manager Yes❑No❑.
This contract has been reviewed and is for signature by the Chair Yes❑No❑.
Manager's Signature: Date:N ((a
Clerk to the Board
Approved by BOCC on the_day of 20 Submitted for Chair signature on the_day of ,20
Clerk's Signature: Date:
Revised March 2012