HomeMy WebLinkAboutR 2013-504. Health - UNC Faculty Physicians for Services in reference to NC Breast & Cervical Cancer Program $6,400 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: UNC Faculty Physicians Party/Vendor Contact Person: Kathryn Grant Contact Phone: Party/Vendor
Address: P.O. Box 168 City Chapel Hill State:NC Zip:27514 Department: Public Health Amount: $6,400 Purpose: Provider will
render services in reference to NC Breast and Cervical Cancer Program Budget Code(s): 10414020-631010 Vendor#21680 (N/A if
new vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check one)New® Renewal ❑ Amendment ❑
Effective Date November 1,2013 Approved by Board Yes❑No❑ Agenda Date: Title of Contract: UNC Faculty
Physicians
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: -t! Date: 1-2���
I irector
(Applicable only to hardware/software purchases or related services)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:
Risk Manasement
Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance Required ❑. Hold
Contract pending receipt of Certificate ❑. With incorporation of Insurance provisions as shown,this contract is approved
by the Risk Manager:
Risk Manager's Signature: Date: f 2�r
IZJII
Financial Services
This Contract is condi ned upon appropriation by the Board of Commissioners YesZNo❑. A budget amendment is necessary
[
before approval Yes No❑. If 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 Control Act:
Financial Services Director's Signature: A4,I A Date: 14141s
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 a ager Most other contracts$1,000 and above). Department Director approval only❑ (Under
$1,000). This contract has been rev an a ved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date:
County Manager
This contract has been reviewed and is ap !ove y the County a ger Yes[Z No❑.
This contract has been reviewed a s fo ig t re b e s❑No❑.
G
Manager's Signature: Date:
Clerk to the Board
Approved by BOCC on the day of 20 . Submitted for Chair signature on the_day of 120
Clerk's Signature: Date:
Revised March 2012