HomeMy WebLinkAboutR 2014-245 Health - NC Public Health Foundation - nicotine replacement therapy 0201 .--7_14,5
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: North Carolina Public Health Foundation Party/Vendor Contact Person: Elizabeth MacLachlan Contact Phone:
919-707-5237 Party/Vendor Address: 5505 Six Forks Road City Raleigh State:NC Zip: 27609 Department:Public Health Amount:
$15,000 Purpose:Provider will provide Nicotine Replacement Therapy for residents of Orange County Budget Code(s): 10414020-
623000 Vendor#N/A (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑No® Contract Type: (Check one)New
Renewal❑ Amendment ❑ Effective Date May 1,2014 Approved by Board Yes❑No❑ Agenda Date: Title of
Contract: Quitline
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:
Cie
Department Director's Signature: QNn 0 Date:
(Applicable on y to a re urchases or related services)This contract has been reviewed and approved by t e n ormation
Technology Director as to technical content an i hnology specifications:
s �gna pre: Date:
Risk Manaaement
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:
Risk Manager's Signature: O Date:
Financial Services
This Contract is conditioned yi'pon appropriation by the Board of Commissioners Yes❑ .No 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: UO2�nc,,, 'CJi Date: I
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). Approva by Ma ager (Most other contracts$1,000 and above). Department Director approval only El(Under
$1,000). This contract has be n evie approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date: 21
County Manaaer
This contract has been reviewed and is ap roved by the County Manager Yes No❑.
This contract has been reviewed an r si na e by e Chair s❑ ❑.
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