HomeMy WebLinkAboutR 2014-397 Health - Elizabeth Krzysztoforska for dental services, patient care at the OCHD clinics L47
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: Elizabeth Krzysztoforska Party/Vendor Contact Person: Elizabeth Krzysztoforska Contact Phone: 336-513-2259
Party/Vendor Address: 128 Summerlin Dr. City Chapel Hill State:NC Zip:27516 Department:Public Health Amount: 35,000
Purpose: Provider will render professional dental services patient care at the OCHD clinics Budget Code(s): 10410120-630000 Vendor#
30702 (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No® Contract Type: (Check one)New❑ Renewal
Amendment ❑ Effective Date July 1,2014 Approved by Board Yes❑No[:] Agenda Date: Title of Contract:Elizabeth
Krzysztoforska
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: p
Department Director's Signature: Date:
(Applicab a on a/software purchases or related services)This contract has been reviewed and approved by the Information
Technology Director as to technical cone hnolo specifications:
Date:
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 U Fpn NE TA ed
by the Risk Manager:
Risk M�anager's Signature: G f'�G.r Date: JUL 2 9 2014
s
1I Financial Services
B Y
This Contract is conditioned on appropriation by the Board of Commissioners Yes❑No A ary
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 Bud et and Fiscal Control Act:
j
Financial Services Director's Signature: A �(�L� Date:
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 b anager La(Most other contracts$1,000 and above). Department Director approval only❑ (Under
$1,000). This contract has been a 'ewed approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date: q 141 4'
County Manager
This contract has been reviewed and is approved by the County Manager Yes No[:].
This contract has been reviewed and is signature by the Chair Yes❑No❑. /
Manager's Signature: Date:
Clgfhk the Board
Approved by BOCC on the day of 20 bm' ed for Chair signature on the day o ,20
Clerk's Signature: Date: /
Revised March 2012