HomeMy WebLinkAboutR 2013-461 Health - Person County Health Dept to reach GTG Project Goals $8,000 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 approval 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 legal review process prior to being routed for signature.
Department
Party/Vendor Name: Person County Health Department Party/Vendor Contact Person: Dawn Coleman Contact Phone: 336-597-2204
Party/Vendor Address: 355 S Madison Blvd City Roxboro State:NC Zip:27573 Department: Public Health Amount: $8,000 Purpose:
PCHD&OCHD will work to reach goals set forth in the CTG Project by supporting programs to promote policy, systems and
evironmental change Budget Code(s):N/A Vendor#N/A (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No®
Contract Type: (Check one)New® Renewal ❑ Amendment ❑ Effective Date October 1,2013 Approved by Board Yes❑No❑
Agenda Date: Title of Contract: Memorandum of Understanding
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: 0
(Applicable on y ses or related services)This contract has been reviewed and approved by the Information
Technology Director as to technical content and information tec cifications:
ate:
Risk Management
Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance Required ❑. Hold
Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,this contract is approved
by the Risk Manager: J j G4
Risk Manager's Signature: ��_��..�� Date:
lO�Z9
Financial Services
This Contract is conditioned on appropriation by the Board of Commissioners Yes❑No[9.1/ A budget amendment is necessary
before approval Yes❑ NoIf budget amendment is necessary, please attach to this form. This instrument has been pre-audited in the
manner required by the Local Government Budget and Fiscal Controlict:
Financial Services Director's Signature: va"4� A V� D 10 36, 13
L ate:
County 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). Approval by Manager..E(Most other contracts$1,000 and above). Department Director approval only❑ (Under
$1,000). This contract has be n/iewed and moved by the Attorney as to legal form and sufficiency:
Attorney's Signature ---- -_ Date:
County Manager
This contract has been reviewed and is ap rov by the County Manager Yes Io❑.
This contract has been reviewe is si ture b t e C 'r Yes❑No❑.
Manager's Signature: Date:
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