HomeMy WebLinkAboutR 2014-570 HR - UNC Department of Family Medicine to Provide Health Screening and Health Coaching for Orange County Employees $25,000 t - ST)
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 Department of Family Medicine Party/Vendor Contact Person: Pam Hoover Contact Phone: 919-966-3907
Party/Vendor Address:UNC-CH,CB 7595 City Chapel Hill State:NC Zip:27599-7595 Department:Family Medicine Amount:
$25,000 Purpose:Provide Health Screening and Health Coaching for Orange County Employees Budget Code(s): 10295020/720022
Vendor#21243 (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No® Contract Type: (Check one)New® Renewal
❑ Amendment ❑ Effective Date 6/1/2014 Approved by Board Yes❑No® Agenda Date: Title of Contract:Agreement
Between Orange County and The University of North Carolina at Chapel Hill for its Department of Family Medicine in the School of
Medicine
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❑Non Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content:
Department Director's Signature: dPi1C6{� � � Date: l j H
IT Director
(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 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 sh
by the Risk Manager: D J lJ
Risk Manager's Signature:_ �� Date: NOV 2 4 2'�14
u1�
Financial Services By
This Contract is conditioned on appropriation by the Board of Commissioners Yes❑No[/ A b
before approval Yes❑ No[5If 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: �� Date: 1 r 7
if laq
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 Manager N(Most other contracts$1,000 and above). Department Director approval only❑ (Under
$1,000). This contract has been eviewed and approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date:
7 County Manager
This contract has been reviewed and is approved by the County Manager No
Yes ❑.
This contract has been reviewed and is for signature by the Chair Yes❑No❑.
/Manager's Signature: Date:
to
Cler 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