HomeMy WebLinkAboutR 2013-388 Health - Piedmont Health Services outside Agecy Performancy Agreement $N/A auy") r 3�` ORANGE COUNTY-CONTRACT CONTROL SHEET
Routing Order: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk
This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager
determines the contract is not appropriate for Manager approvai the Manager shall submit the contract for BOCC approval. Contracts for
BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should
be completed through the levaI review process.prior to being routed for signature.
De az Aent
Party/Vendor Name: Piedmont Health Services Party/Vendor Corvact Person: Brian Toomey Contact Phone: 781-687-9500
Party/Vendor Address:229 Lloyd Street City Carrboro State: NC Zip: 27510 Department:Public Health Amount:N/A Purpose:
Outside agency performance agreement Budget Code(s): 10414020-630000 Vendor#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: Outside Agency Agreement
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:
Department Director's Signature: ~ Date:
Director
(Applicable only to hardware/software purchases or related se7vic•es)This contract has been reviewed and approved by the Information
Technology Director as to technical content and information technology specifications:
IT Director's Signature: Date:
ll`:i�l. 'lan;�e►:rent
Include the following coverages: i CGL; [Auto; �� •i i �I ofessional; ❑ Property; OR No Insurance Required ❑. Hold
Contract pending receipt of Certificate of Insurance:; of Insurance provisions as shown,this contract is approved
by the Risk Manager:
Risk Manager's Signature: `� ' Date: �U �
Financial Services
This Contract is conditioned on appropriation by the Board of Commissioners Yes❑Noa. A budget amendment is necessary
before approval Yes❑Nog.If budget amendment is necessary, please attach to this form. This instrument has been pre-audited in the
manner required by the Local Government Budgey and Fiscal Control Act: r
Financial Services Director's Signature: Date: �O I
Countv Attorney
Approval by Board ❑ (Contracts $90,000 00 or more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approv by Manager&(Most other contracts$1.,000 and above). Department Director approval only❑ (Under
$1,000). This contract has e re e d and approved by the Atcnn:c y_s to legal form and sufficiency-
Attorney's Signature _ _ Date:
County Manager
This contract has been reviewed and is approved by the County Manager YeADA00.
This contract has been reviewed and is for sig re b the C it Yes❑No
Manager's Signature: Date:
lerk 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