HomeMy WebLinkAbout2015-466-E Housing - Zahra Brooks for Arabic and French interpretation $3,000 DocuSign Envelope ID:5B6FF7D8-5B74-4BD3-BC2C-DDBAEB3C9E82
ORANGE COUNTY
COUNTYWIDE INTERPRETER CONTRACT
NORTH CAROLINA (15,000 OR LESS)
THIS AGREEMENT, made and entered into this 1 st day of Tuly, 2016, ("Effective Date")by and
between Orange County, North Carolina, a body politic and corporate oiganized under the laws of the State
of North Carolina, (the"County"),and Zahra Brooks (the"Provides
WITNESSETH:
For the purpose and subject to the fbllowing terms and conditions hereinafter set fbrth, the County
hereby contacts for the services of the Providet, and the Provider agrees to provide the following
Interpretation Services (hereinafter referred to as "Services")to the County in accordance with the terms of
this Agreement, time being ofthe essence
1 Contract. This Contract consists of this document and additional documents checked
below:
a„ For-Health Department:
i. ® Health Department Additional Terms and Conditions
ii, Business Associates Agreement
iii ® Condition of Contract Statement
b, For'Department o#'Social Services:
i. ❑The General Terror and Conditions(Attachment A);
ii, ®The Scope of Work, description of'services, and rate (Attachment B);
iii ® Federal CertificationRegat'ding Drug-Free Workplace (Attachment C);
iv, ® Conflict of Interest (Attachment D);
v ®No Overdue Taxes (Attachment E);
vi ❑ Outcomes and Reporting(Attachment N)
These documents constitute the entire agreement between the Parties and supersede all prior oral
Or Wlitten statements Or' agreements
2 Provider's Responsibilities:
a. The Provider shall be qualified to interpret between English andArabic and English and
Fr ench with the client and County staff
b Professional Conduct. The Provider shall adhere to the standards of professional conduct of
an interpreter while conducting the services to include the following:
i the Provider shall relate to all County clients and staff in a respectful and
professional manner.
ii the Provider will interpret the information being shared between client/family and
staff as clearly as possible, without additional personal comments ox biases on the
topic being discussed
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iii. The provider when providing interpretation services will interpret the information as
cleanly as possible without changing the meaning and the intent of the conversation
iv The Provider will interpret the information to the best of his/her,ability
c Client Confidentiality..
i The Provider acknowledges that she/he may have access to information that is
confidential and provided by state and federal laws and agrees to comply with all
privacy policies, regulations, and laws as well as the Health Insurance Portability
and Accountability Act(HIPAA) of 1996 (P L.104.491).
ii. The Provider agrees to protect confidential information (e.g., client name,
appointment type,telephone number, health information)that he/she may receive in
doing business with County The Pxovidei should ensure proper, safe storage and
protection of client information during use, and shredding/deletion of such
information when it is no longer necessary for business purposes.
iii Breaches of client confidentiality will result in automatic termination of this
Agreement
d Scopeof'Services.
i Procedures and Guidelines Upon Acceptance of an Interpretation Assignment:
1 The Provider agrees to give at least 2.4 hoax notice if he/she is unable to
participate in a scheduled client contact
2. The Provider will be expected to make confirmation phone calls to clients in
advance of an assigned appointment, when feasible, and when the Provider
is provided the information by County staff The Pxovidex should notify
County staff as soon as possible if the client has told the Provider that he/she
will not be able to make the appointment and/oi if' he/she needs to
reschedule. Ihese confirmation calls will not be paid for separately,but are
considered part of the service when the Provider accepts an assignment fox
an appointment
3 The Provider shall not have contact with County clients without County
staff' being present, unless specifically asked by staff to call clients to
confirm or schedule appointments It is not acceptable for the Provider to
give out his/her home telephone number or cell phone number fox latex
contact between the family and Pxovidex.
3 County's Responsibilities. County will compensate Provider as provided in subsection 4 fox
interpretation services at the rate prescribed Per hour reimbursement will begin at the time the
Provider meets with County staff for the appointment and ends at the time the staff and
interpreter contact is completed. Ihere will be a minimum of one (1) hour of service for an
appointment. There will be a minimum of one (2) hour of service fox an appointment County
will reimburse the Provider for two (2) hours of interpretation service in the event of a same day
cancelled appointment That includes appointments fox clients who do not show up for an
appointment, and for those who cancel an appointment with less than 24 hour notice.
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4. Payment fbr Services: The County agrees to pay at the rates specified for Services satisfactorily
performed in accord with this Agreement.
a. Compensation. Compensation for Services shall include all compensation due the
Provider from the County for all Services provided under this Agreement including
Reimbursable Expenses as specified below.
i) Basic Services The amount to be paid by the County shall not exceed Three
Thousand Dollars ($3,000), to be paid at a rate of $40/hour for Interpretation
Services. Payment shall be made within thirty (30) days of an invoice properly
submitted to County Should Provider fail to perform its duties under the terms of this
Agreement, County may, without fault or penalty, withhold any payment associated
with the work to be performed until such time as said work is completed
ii) Reimbursable Expenses. Reimbursable expenses are in addition to the fees for
Services. Mileage shall be a reimbursable expense for travel to and from the
job site to the extent reasonable and actually incuxred by the Provider with
respect to the Services provided:
b The Provider shall complete and submit the County Invoice fox Payment of Interpretation Services
form to County staff at the time the service is rendered. County staff'will verify the information,
sign and forward the form for payment of services. Reimbursable expenses shall be
compensated by the County along with invoices for Services provided by Provider.
Payment of Reimbursable Expenses shall be subject to Provider's timely submission of
valid receipts for any such expenses and approval by the County. Any additional charges
not specified herein, must be mutually agreed to in advance by County and Provider and
documented in writing with a letter signed by authorized representatives for County and
Provider and, subject to budgeted funds
c. Por interpretation services:
i) The Provider will record the start and finish time worked to the minute. After the fast hour of
service,payment will be calculated and paid per minute
ii) The Provider shall submit one invoice per client, unless there is a block of appointments
without interruption.. Without interruption means that there were no cancelled appointments
and no lunch hour included. This is appropriate for a group of clients who are served for the
same type of appointment, at the same location For question, contact the departmental
contact.
iii) In the event of a cancelled appointment, the Provider is required to stay until relieved of duty
by the individual in charge County staff may require other interpreter-related services in place
of the scheduled appointment As stated above, the Provider may submit an invoice in the
event of a broken appointment (with less than 24 hour notice)
iv) If the Provider is assisting County staff' with a large volume of phone calls outside of a
scheduled appointment time, the Provider should complete a Call Log to submit along with an
invoice describing the services performed. Ihis type of service is paid by the minute,without a
one hour minute requirement for payment.
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v) In the case of an unexpected closing or delayed opening (e g, inclement weather) of the
County Offices when providing interpretation services, the Provider shall not be paid far
missed appointments. When in doubt,the Provider can call 732-8 181 to see if'county offices
we open ox-are on a delayed schedule When possible, the Provider is also asked to help call
his/her scheduled clients to inform them of the delay of closing
5 Ierm.. the term of this Agreement shall be from July 1,2015 to Tune 30,2016.
6 Errors and Omissions. Provider represents and agrees that Provider is qualified to perform and fully
capable of performing and providing the services required or necessary under this Agreement in a
fully competent, professional and timely manner to the satisfaction of the County.. Provider shall be
responsible for all errors or omissions, in the performance of the Agreement Provider shall correct
any and all errors, omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost
to the County
7 Additional Ierms and Condition. The County may have additional terms and condition that shall be
provided as attachment 1, and shall be attached and are hereby incorporated by reference,
8 Precedence Among Contract Documents: In the event of a conflict between ox among the
terms of the Contract Documents, the terms in the Contract Document with the highest
relative precedence shall prevail. The order of precedence shall be the order of documents
as listed in Paragraph 1, above, with this contract document having the highest precedence
then the first listed document and the last-listed document having the lowest precedence. If'
there are multiple Contract Amendments, the most recent amendment shall have the highest
precedence and the oldest amendment shall have the lowest precedence.
9 Non—waiver: Failure by County at any time to require the performance by Provider of any of the
provisions hereof shall in no way waive or affect the County's right hereunder to enforce the same,
nor shall any waiver by the County of any breach be held to be a waiver of any succeeding breach or
a waiver of this Non-Waiver Clause
10. Independent Contractor: The Provider shall operate as an independent Provider, and the County shall
not be responsible for any of the Provider's acts or omissions The Provider shall not be treated as
an employee with respect to the Services performed hereunder for federal or state tax,unemployment
or workers' compensation purposes the Provider- understands that neither federal, nor state, nor
shall payroll tax of any kind be withheld of paid by the County on behalf of the Provider or the
employees of the Provider.
11. Insurance: the County recommends that Provider obtain, at its sole expense,all'insurance needed to
adequately insure itself during the performance of these services.
12. Indemnity: The Provider agrees to defend, indemnify, and hold harmless Orange County from all
losses,liabilities,claims,demands,suits, costs,damages or expenses(including reasonable attorney's
fees) arising from any injury, including death,to any person or persons or damage to or destruction
of any property caused in whole of in part by any negligent or intentional act or omission on the part
of the Provider.
13 Termination: This Agreement may be terminated at any time by mutual written agreement of the
parties or by the County upon written notice to the Provider.
14. Entire Agreement: The patties have read this Agreement and agree to be bound by all of its terms,
and farther agree that it constitutes the complete and exclusive statement of the Agreement between
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the parties unless and until modified in writing and signed by the parties Modifications may be
evidenced by telefacsimile signature This Agreement together with any amendments or
modifications may be executed electronically All electronic signatures affixed hereto evidence the
intent of the Parties to comply with Article 1IA and Article 40 of North Carolina General Statute
Chapter 66.
15 Governing Law: Both parties agree that this Agreement shall be governed by the laws of the State of
North Carolina_ Should either patty initiate litigation to settle any dispute involving the terms of this
Agreement such litigation shall be initiated in the General Court of Justice of'North Carolina seated
in Orange County, North Carolina. Provider shall at all times remain in compliance with all
applicable local, state, and federal laws, rules, and regulations including but not limited to all anti-
discrimination laws.
16 Non A]2propriation: Provider acknowledges that County is a governmental entity, and the validity of
this Agreement is based upon the availability of public funding under the authority of its statutory
mandate In the event that public hands are unavailable and not appropriated for the performance of
County's obligations under this Agreement, then this Agreement shall automatically expire without
penalty to County immediately upon written notice to Provider of the unavailability and non-
appropriation of public funds
IN WITNESS WHEREOF,Orange County and the Provider have signed this Agreement, effective
as of the day first written above.
» !� ,
OR"'T QacuSignad 6y'T==T I RI Y pacuSignad 6y � Woks
156V n.6t Cli7l 1 lt.V$l4 C ,�I bks
By' 033 7ga467EGE477... By' — D010146...
Bonnie Hammersley,County Manager Title:
interpreter
200 S. Cameron St. 1000 Discovery Way Apt 1017
P.0 Box 8181 Durham,NC 27703
Hillsborough,NC 27278
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Orange County Health Department (hereinafter-r-eferred to as "OCHD")
Additional Terms and Conditions
These are additional terms and conditions to the Agreement between Orange County and the
(PROVIDER) to the Countywide Interpreter Translator Contract of$15,000 or less The additional
terms and conditions shall supersede any terms in the original contract and ate hereby incorporated
as follows:
Add to Section 2. b
v. The Provider will follow the National Code of Ethics and Standards of
Practice outlined by the National Council on Interpreting in Health
Care which can be found at www.ncihc.or a and is hereby incorporated
by reference
vi. the Provider is required to sign the OCHD Conditions of Contract
Statement containing the confidentiality, Iitle X and public health
activities in emergency situations information which is hereby
incorporated by reference.
Add to Section 2 d.i.3 the following sentence:
The Provider should generally instruct clients to call the Health
Depattment front desk staff or the Spanish voicemail line at 644-3350
(when language appropriate) to schedule an appointment or to inquire
about services
Add Section 2.e.
c Medical Documentation. Prior to beginning work,the Provider is required to:
i Provide proof'of immunity to vaticella, measles,mumps and rubella Proof
of immunity must be one of the following: medical records diagnosing the
disease, laboratory records confirming the disease, laboratory records
documenting positive disease titers, or medical records documenting receipt
of 2 doses of each vaccine (Exception: If the Provider has documentation
of only one dose of vaccine, the Provider must provide documentation of a
second dose within 60 days of'the first day of contract work)
ii Provide proof'of a TB screening and results to OCHD The screening can
be one of the following:
1. Receipt of a I skin test (IS 1) if the Provider has no history of TB
infection/disease or of a positive IS (Note: If the Provider has not
had an additional I S I within the previous 12 months, a second I S I
will be required one week after the first to establish an accurate
baseline.)
2 Completion of a TB Screening Form by a medical provider if the
Provider has a history of TB disease or of having a positive TSI.
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iii Provide proof of Tdap vaccine
iv.Provide proof of current influenza(flu) vaccine
v. Unless otherwise provided, proof of immunization must take the
form of one of the following: Provider's immunization record or
medical record signed by a representative of the Provider's healthcare
practice In either case both the Provider's name and the date of
immunization must be present Only vaccines approved by the
Centers for Disease Control and Prevention
(wwwcdc.gov/flu/piotect/vaceine/vaceineshtin) will be accepted
The provider is responsible fox the costs associated with acquixing the
vaccination.
Replace Section 3 with the following paragraph:
3. Coun 's Responsibilities. County will compensate Provider as provided in subsection 4
far interpretation and translation services at the rate prescribed Per hour reimbursement
will begin at the time the Provider meets with County staff for the appointment and ends
at the time the staff and interpreter contact is completed There will be a minimum of
one (1) hour of service foar an appointment. OCHD will reimburse the Provider fox one
(1)hour of interpretation service in the event of a same day cancelled appointment. That
includes appointments for clients who do not show up for an appointment, and for those
who cancel an appointment with less than 24 hour notice Exception: "Family"Refugee
Health Assessment (communicable disease and/or physical exam) appointments with 3
oz morc fancily members will only be reimbursed for a total of two (2) hours in the case
of same day cancelled appointments, OCHD will not reimburse the Provider if an
appointment is cancelled with more than 24 hour notice.
Replace Section 4 b iii the following paragraph:
iii In the event of a cancelled appointment,the Provider is required to stay until
relieved of duty by the nurse supervisor or the individual in charge of
clinical operations. OCHD staff may require other interpreter-related
services in place of the scheduled appointment. As stated above, the
Provider may submit an invoice in the event of a broken appointment (with
less than 24 hour notice).
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BUSINESS ASSOCIATE AGREEMENT
This Business Associate Agreement ("Agreement") is made effective the First day of July, 2015,
by and between Orange County Government through its Orange County Health Department ("Covered
Entity"), and Zahra Brooks, (`Business Associate"). Covered Entity and Business Associate may be
referred herein individually as a"Party" or collectively as the "Parties" This Agreement supersedes any
previously executed Business Associate Agreement between the Parties
WTTNESSETH:
WHEREAS, Sections 261 through 264 of the federal Health Insurance Portability and
Accountability Act of 1996 ("HIPAA"), Public Law 104-191, as modified by the Health h formation
Technology for Economic and Clinical Health Act ("HTTECH"), Public Law 111-5, known as "the
Administrative Simplification provisions," direct the Department of Health and Human Services to
develop standards to protect the security,confidentiality and integrity of health information;and
WHEREAS, pursuant to the Administrative Simplification provisions, the Secretary of Health and
Human Services ("Secretary") has issued regulations modifying the Privacy, Security, Breach
Notification, and Enforcement Rules at 45 CFR Parts 160 and 164, as the same may be amended from
time to time(the"HIPAA Security and Privacy Rule"); and
WHEREAS, the Parties wish to enter into or have entered into an arrangement whereby Business
Associate will provide certain services to Covered Entity, and, pursuant to such arrangements, Business
Associate may be considered a"Business Associate"of Covered Entity as defined in the HIPAA Security
and Privacy Rule (the agreement evidencing such arrangement is detailed below and hereinafter referred
to as the"Service Agreement(s)");and
WHEREAS, Business Associate may have access to Protected Health Information (as defined below) in
fulfilling its responsibilities under such arrangement;
THEREFORE, in consideration of the Parties' continuing obligations under the Service Agreement,
compliance with the HIPAA Security and Privacy Rule, and other good and valuable consideration, the
receipt and sufficiency of which is hereby acknowledged, the Parties agree to the provisions of this
Agreement in order to address the requirements of the HIPAA Security and Privacy Rule and to protect
the interests of both Parties
I. DEFMTJONS
(a) Service Agreement Agrecment(s) for services affected by this HIPAA Business
Associate Agreement, which this Business Associate Agreement shall be attached to, and is (are) hereby
incorporated by reference, and which shall be taken and considered as a part of this document the same as
if fully set out herein:
COUNIYWIDE INTERPREIER CONTRACT ($15,000 OR LESS)
(b) Catch-all Provision. Except as otherwise defined herein, any and all capitalized terms in
this Agr cement shall have the definitions set forth in the HIPAA Security and Privacy Rule,45 CF'R Parts
160 and 164, subparts A and E In the event of an inconsistency between the provisions of this Agreement
and mandatory provisions of the H1PAA Security and Privacy Rule, as amended,the HIPAA Security and
Privacy Rule shall control. Where provisions of'this Agreement are different than those mandated in the
HIPAA Security and Privacy Rule, but are nonetheless permitted by the HIPAA Security and Privacy
Rule,the provisions of this Agreement shall control
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(c) Electronic Protected Health Information. Protected.Health hafoimation that is transmitted
by or maintained in Electronic Media(as defined in the HIPAA Security and Privacy Rule)..
(d) Protected Health Information. "Protected Health hformation" shall have the same
meaning as the term in 45 CIR § 160 103, limited to the information created or received by Business
Associate from of on behalf of Covered Entity and includes without limitation "Electronic Protected
Health hnformation."Business Associate acknowledges and agrees that all Protected Health Information
that is created or received by Covered Entity and disclosed or made available in any form,including paper
record, oral communication, audio recording, and electronic display by Covered Entity or its operating
units to Business Associate or is created or received by Business Associate on Covered Entity's behalf
shall be subject to this Agreement
(e) Required by Law. "Required by Law" shall have the same meaning as the terra. in 45
CFR § 164 10.3.
IF OBLIGATIONS AND ACIMIIES OF BUSINESS ASSOCIATE
(a) Use and Disclosure Business Associate agrees to fully comply with the requirements
under the HIPPA Security and Privacy Rule applicable to Business Associates and not to use of disclose
Protected Health Information other than as permitted or required by this Agreement, the Service
Agreement or as Required by Law To the extent Business Associate carries out obligations of Covered
Entity under the HIPAA Security and Privacy Rule, Business Associate shall comply with the applicable
provisions of the HIPAA Security and Privacy Rule as if'such use of disclosure were made by Covered
Entity, Business Associate agrees to comply with Covered Entity's policies regarding the minimum
necessary use or disclosure of'Piotected Health Information
(b) Appropriate Safeguards. Business Associate agrees to use appropiiate safeguards to
prevent use or disclosure of Protected Health Information other than as provided £or by this Service
Agreement(s), this Agreement or as Required by Law Ihis includes the implementation physical,
technical and administrative safeguards to prevent use or disclosure of Protected Health Information other
than as permitted in this Agreement or Required by Law and reasonably and appropriately protect the
confidentiality, integrity, and availability of any Electronic Protected Health Information that it creates,
receives, maintains, or transmits on behalf of Covered Entity as required by the HIPAA Security and
Privacy Rule. The Business Associate shall maintain appropriate documentation of its compliance with
the HIPPA Security and Privacy Rule, including, but not limited to, its policies, procedures, iecoids of
training and sanctions of members in its woikforce.
(c) Assurances. Business Associate agrees to provide Covered Entity with written
assurances that any Protected Health Information placed on any type of mobile media, including, but by
no means limited to, lap top computers, Ipads and mobile phones, is encrypted in accordance with
guidance issued by the Secretary.
(d) Agents and Subcontractors. Business Associate shall require any agents, including any
subcontractors, to whom it provides Protected Health Information fiom Covered Entity that is created,
received, maintained or transmitted on behalf of Business Associate to agree by written contract with
Business Associate to the same (or greater) restrictions, conditions and requirements that apply to
Business Associate with respect to such information, and to agree to implement reasonable and
appropriate safeguards to protect any of such information that is Electronic Protected Health Information.
In addition, Business Associate agrees to take reasonable steps to ensure that its employees' actions or
omissions do not cause Business Associate to breach the terms of this Agreement
(e) Mitigation of Breach Business Associate agrees to mitigate, to the extent practicable,
any harmful effect that is known to Business Associate of a use or disclosure of Protected Health
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Information by Business Associate in violation of the rcquizements of this Agreement, as well as to
provide complete cooperation to Covered Entity should Covered Entity elect to review or investigate such
noncompliance or Security Incident. Business Associate shall cooperate in Covered Entity's breach
analysis and/or risk assessment, if requested Furthermor®, Business Associate shall cooperate with
Covered Entity in the event that Covered Entity determines that any third parties must be notified of a
Breach,provided that Business Associate shall not provide any such notification except at the direction of
Covered Entity.
(f) Breach Reporting. Business Associate shall report in writing to Covered Entity's Privacy
Officer (see Exhibit A), any use or disclosure of Protected Health Information that is not in compliance
with the terms of this Agreement, as well as any Security Incident and any actual or suspected Breach, of
which it becomes aware, without unreasonable delay, and in no event later than forty-eight(48) hours of
such discovery. Tr or purposes of this Agreement, "Security Incident" means the attempted or successful
unauthorized access, use, disclosure, modification, or destruction of information or interference with
system operations in an information system Such notification shall contain the elements required by 45
C.F.R. § 164.410
(g) Compliance. To the extent applicable, Business Associate will comply with(i) Covered
Entity's Notice of Privacy Practices; (ii) any limitations to which Covered Entity has agreed in regard to
an Individual's permission to use or disclose his or her Protected Health Information; and (iii) any
restrictions to the use or disclosure of Protected Health Information to which Covered Entity has agreed
or is requiredt.o agree.
(h) Government Access Business Associate will make its internal practices, books and
records available to the Secretary of the Department of Health and Human Services for purposes of
determining compliance with the terms of the HIPAA Security and Privacy Rule, and, at the request of
the Secretary,will comply with any investigations and compliance reviews,permit access to information,
and cooperate with any complaints, as Required by Law_ Without unreasonable delay and, in any event,
no more than 48 hours of receipt of the request or notification, Business Associate will notify Covered
Entity in writing of any request by any governmental entity, or its designee, to review Business
assessment of any kind.
(i) Electronic Transactions If Business Associate conducts any Standard Itansactions for or
on behalf of Covered Entity, Business Associate shall comply with the requirements under the Electronic
Transaction Rule
0) Audit. Business Associate shall permit Covered Entity, in its discretion, to conduct an
audit of Business Associate's compliance with this Agreement, HIPAA, and HITECH Such audit may
consist of an onsite visit., a series of inquiries that require written responses, or both Business Associate
shall promptly and completely respond to Covered Entity's requests for information in support of the
audit, which shall not be conducted more than once annually except in cases of an actual or reasonably
suspected Security Incident or reasonably suspected noncompliance with this Agreement, HIPAA or
HITECH Each Party shall bear its own costs associated with the audit.
(k) Identity Ihefl Business Associate shall implement Identity Theft Monitoring Policies
and Procedures to protect any patient information that may be breached by the Business Associate to the
extent applicable under the Federal bade Commission's Red Flag Rules.
(1) HITECH Compliance Business Associate shall:
A Not receive, directly or indirectly, any impermissible remuneration in exchange
fbr Protected Health Information or Electronic Protected Health Information,
except as permitted by HITECH § 13405(d) or the HIPPA Regulations;
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B Comply with the marketing and other restrictions applicable to Business
Associates contained in HIIECH § 1.3406 and the HIPPA Regulations;
C Io the extent required under HITECH§ 13404, fully comply with the applicable
requirements of 45 CFR 164 502(c)(2) for each use and disclosure of Protected
Health Information;
D. To the extent required under HIIECH § 13401, fully comply with 45 CFR §§
164.308, 164.310, 164.312, and 164.316;
E. To the extent required under HITECH §§13401 and 13404, comply with the
additional privacy and security requirements that apply to Covered Entities in the
same manner and to the same extent as Covered Entity is required to do so; and
F To the extent mquued under the HIPPA Regulations, comply with the privacy
and security requirements that apply to Business Associates
(m) State Privacy Laws.. Business Associate shall understand and comply with state privacy
laws to the extent that such privacy laws arc not preempted by HIPPA or HIT ECH
III PERMI'ZTED USES AND DISCLOSURES BY BUSINESS ASSOCIATE
(a) Use of Protected Health Information on Behalf of Covered Entity. Except as otherwise
limited in this Agreement, Business Associate may use or disclose Protected Health Information to
perform functions, activities or services fox; or on behalf of, Covered Entity described in the Service
Agreement, provided that such use or disclosure would not violate the HIPPA Security and Privacy Rule
if it were made by Covered Entity or would not violate the Covered Entities minimum necessary policies
(b) Other Uses of Protected Health Information. Except as otherwise limited in this
Agreement,Business Associate may use Protected Health Information within its woxkfoxce for the proper
management and administration of Business Associate not to include Marketing or Commercial Use and
to carry out the legal responsibilities of Business Associate; and
(c) Ihird Party Confidentiality. Except as otherwise limited in this Agreement, Business
Associate may disclose Protected Health Information for the proper management and administration of
Business Associate or to carry out the legal responsibilities of Business Associate, provided that if'
Business Associate discloses any Protected Health Information to a third party for such purpose, the
Business Associate shall enter into a written agreement with such third party requiring the following:
A Disclosure only as Required by Law; or
B Business Associate obtains reasonable assurances from the person to whom the
information is disclosed that the information will remain confidential and will be used or
further disclosed only as Required by Law or for the purpose for which it was disclosed
to the person, and the person notifies Business Associate of any instances of which it is
aware in which the confidentiality, integrity, and of availability of the Protected Health
Information has been breached immediately upon becoming aware.
(d) Business Associate may provide data aggregation services relating to the health ease
operations of Covered Entity pursuant to any agreements between the Parties evidencing their business
relationship as permitted by 45 CFR§ 164 504(e)(2)(i)(B)
(e) Other Uses Strictly Liudted. Nothing in this Agreement shall permit the Business
Associate to share Protected Health Information with Business Associate's affiliates or contractors except
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for the purposes of the Service Agreement(s) between the Covered Entity and Business Associate(s)
identified in Section I(a) of'this Agreement.
(f) Covered Entity Authorization far- Additional Uses Any use of Protected Health
Information by Business Associate, its affiliate or Contractor, other than those purposes of this
Agreement, shall require express written authorization by the Covered Entity, and a Business Associate
Agreement ox amendment as necessary. Activities which are prohibited include, but are not limited to,
Marketing,as defined by 45 CFR§ 164.503 or the sharing for Commercial Use or any purpose construed
by Coveted Entity as Marketing or Commercial Use, even if such sharing would be permitted by federal
or state laws,
(g) Business Associate may de-identify Protected Health Information only at the specific
direction of and only for the use of Covered Entity., Business Associate may not sell Protected Health
Information except at the direction of'Covered Entity and in compliance with the requirements of the
HIPAA Security and Privacy Rule.
IV AVAILABILITY OF PHI
(a) Access to Protected Health Information. Business Associate agrees, in the event the
Business Associate maintains protected health information in a Designated Record Set,to make available,
within ten(10) days of a request by Coveted Entity in a time and manner designated by Covered Entity,
Protected Health Information in a Designated Record Set, to Coveted Entity or as directed by Covered
Entity, to an individual in order to meet the requirements of 45 CFR § 164.524 of the HIPAA Security
and Privacy Rule
(b) Amendments to Protected Health Information. In the event that the Business Associate
maintains Protected Health Information in a Designated Record Set, Business Associate agrees to make
any amendment(s) to Protected Health Information in a designated record set that the Covered Entity
directs or agrees to pursuant to the HIPAA Security and Privacy Rule at the request of Covered Entity of
an individual,within ten(10)days of receipt of a request from Covered Entity and in the time and manner
designated by Covered Entity.
(c) Accounting of Disclosures, Business Associate agrees to maintain and make available
the information required to provide an accounting of disclosures, as required by 45 CFR § 164 528 of'the
HIPAA Security and Privacy Rule Business Associate will comply with Covered Entity's policy
regarding accounting of disclosures.
(d) Document Disclosures In the event an Individual makes a request under this Section of
the Agreement directly to Business Associate, Business Associate will notify Covered Entity of such
request within three (3) business days and shall cooperate with, and act only at the direction of Covered
Entity in responding to such request.
V OBLIGATIONS OF COVERED ENIIIY
(a) Notice of Privacy Practices. Covered Entity shall provide Business Associate with the
notice of privacy practice that Covered Entity produces in accordance with 45 CFR § 164.520, as well as
any changes to that notice
(b) Notice of Changes in Individual's Access or Protected Health Infottnation Covered
Entity shall provide Business Associate with any changes in, or revocation of, permission by an
Individual to use or disclose Protected Health Information, is such changes affect Business Associate's
permitted or required uses
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(c) Notice of Restriction in Individual's Access to Protected Health Information. Covered
Entity shall notify Business Associate of any restrictions to the use or disclosure of Protected Health
Information that Covered Entity has agreed in accordance with 45 CFR § 164 522 to the extent that such
restriction may affect Business Associate's use of Protected Health Information.
VI PERMISSABLE REQUESTS BY COVERED ENTITY
Requests Permissible Under HIPAA. Coveted Entity shall not request Business Associate to use
or disclose Protected Health Information in any manner that would not be permissible under the Privacy
or Security Rule
VII. TERMINATION
(a) Term, This Agreement shall be effective as of the date first set forth above and shall
terminate upon the earlier of (i) the termination of all agreements between the parties, and (ii) the
termination by Covered Entity for cause as provided hetcin.
(b) Termination fbr Cause. Notwithstanding anything in this Agreement to the contrary,
Covered Entity shall have the right to terminate this Agreement and the Service Agreement immediately
if Covered Entity determines that Business Associate has or will violated any material term of this
Agreement Upon Covered Entity's knowledge of a material breach by Business Associate, Covered
Entity shall provide an opportunity for Business Associate to cure the hreach or end the violation.
Covered Entity may terminate this Agreement if Business Associate does not cure the breach or end the
violation within the time period specified by Covered Entity If termination, cure or end of the violation
is not feasible, Covered Entity may report the violation to the Secretaty
(c) Obligation of Business Associate Upon Termination. At termination of this Agreement,
the Service Agreement (or any similar documentation of the business relationship ofthe Patties), or upon
request of Covered Entity,whichever occurs fast,Business Associate, shall:
A. if feasible,return(in a manner or process approved by the Coveted Entity) or destroy
all Protected Health Information, regardless of fbtrn, including but not limited to
paper or electronic format, received from Covered Entity, or created, maintained or
received by Business Associate on behalf' of Covered Entity Business Associate
shall retain no copies of the Protected Health Information. This provision shall also
apply to Protected Health Information and other confidential information in the
possession of subcontractors or agents of'Business Associate.
B If such return or destruction is not feasible, Business Associate shall (i) retain only
that Protected Health Information necessary for Business Associate to continue its
proper management and administration or to catty out its legal responsibilities; (ii)
return or destroy the remaining Protected Health Information that the Business
Associate still maintains in any form; (iii) extend the protections of this Agreement to
the retained Protected Health Information; (iv) limit further-uses and disclosures to
those purposes that make the return or destruction of the Protected Health
Information not feasible; and (v) return or destroy the retained Protected Health
Information when it is no longer needed by Business Associate..
(d) Survival This paragraph shall survive the termination of this Agreement and shall apply
to Protected Health Information created, maintained, or rcceived by Business Associate and any of its
subcontractors
VIII. MISCELLANEOUS
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(a) Indemnification. Business Associate agrees to indemnify, defend, and bold harmless
Covered Entity, its officers, agents, contractors and agents, against, and in respect of, any and all claims,
losses, expenses, costs, damages, obligations, penalties, and liabilities which Covered Entity may incur
by reason of Business Associate's breach of or failure to perform any its obligations pursuant to this
Agreement, including but not limited to any injury or damages arising from any noncompliance with this
Agreement or any Security Incident attributable to the negligence of Business Associate, including
failure to execute the terms of this Agreement Further,Business Associate agrees to indemnify, defend,
and hold harmless Covered Entity, its officers, employees, contractors and agents, against all costs and
expenses, including but not limited to, reasonable legal expenses, which are incurred by or on behalf'of
Business Associate in connection with the defense of such claims
(b) Disclaimer Covered Entity makes no warranty or representation that compliance by
Business Associate with this Agreement,H1PAA, HITECH, or the HIPAA Regulations will be adequate
or satisfactory for Business Associate's own purposes. Business Associate is solely responsible for all
decisions made by Business Associate regarding the safeguarding of'lProtected Health Information
(c) Assistance in Litigation or Administrative Proceedings. Business Associate shall make
itself; and any subcontractors, employees, affiliates or agents assisting Business Associate in the
performance of its obligations under this Agreement, available to Covered Entity, at no cost to Covered
Entity,to testify as witnesses, or otherwise, in the event of litigation or administrative proceedings being
commenced against Covered Entity, its directors, officers or employees based upon a claimed violation
of HWAA, HITECH, the 111PAA Regulations, ar other laws relating to security and privacy, except
where Business Associate or its subcontractor, employee or agent is named adverse party.
(d) Survival the obligations of Business Associate under this Agreement shall survive the
expiration, termination, or cancellation of this Agreement, the Service Agreement and/or the business
relationship of the parties, and shall continue to bind Business Associate, its agents, employees,
contractors, successors, and assigns as set forth herein.
(e) Ownership of Information Covered Entity holds all right, title, and interest in and to the
Protected Health Information and Business Associate does not hold and will not acquire by virtue of this
Agreement or by virtue of providing goods or services to Covered Entity, any right, title, or interest in or
to the PHI or any portion thereof'.
(f) Right to Injunctive Relief. Business Associate expressly acknowledges and agrees that
the breach, or threatened breach,by it of any provision of this Agreement may cause Covered Entity to be
irreparably harmed and that Covered Entity may not have an adequate remedy at law. Therefore,Business
Associate agrees that upon such breach, or threatened breach, Covered Entity will be entitled to seek
injunctive relief'to prevent Business Associate from commencing or continuing any action constituting
such breach without having to post a bond or other security and without having to prove the inadequacy
of any other available remedies Nothing in this paragraph will be deemed to limit or abridge any other
remedy available to Covered Entity at law or in equity Except as expressly stated herein or in the HIPAA
,Security and Privacy Rule, the parties to this Agreement do not intend to craate any rights in any third
parties
(g) Amendment The Parties agree to take such action as is necessary to amend this
Agreement from time to time as is necessary for Covered Entity to comply with the requirements of the
HIPSS Regulations. In addition, this Agreement may be amended or modified by the Parties only in
writing
(h) Assignment. No Party may assign its respective rights and obligations under this
Agreement without the prior written consent of the othet Party.
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(i) Independent Contractor. None of'the provisions of this Agreement are intended to create,
nor will they be deemed to create any relationship between the Parties other than that of independent
parties contracting with each other solely for the purposes of effecting the provisions of this Agreement
and any other agreements between the Parties evidencing their business relationship This Agreement
will be governed by the laws of the State of North Carolina No change, waiver or discharge of any
liability or obligation hereundet on any one or more occasions shall be deemed a waiver of performance
of any continuing or other obligation, or shall prohibit enforcement of any obligation, on any other
occasion
(j) Regulatory References A reference in this Agreement to a section in HIPAA, HITECH
or the HIPAA Regulations means the section as it currently is in effect or as amended.
(k) Interpretation. Any ambiguity in this Agreement shall be resolved in favor of a meaning
that permits Covered Entity to comply with the HIPAA Regulations The parties agree that, in the event
that any documentation of the arrangement pursuant to which Business Associate provides services to
Covered Entity contains provisions relating to the use or disclosure of Protected Health Information that
are more restrictive than the provisions of this Agreement, the more restrictive provisions will control
the provisions of this Agreement are intended to establish the minimum requirements regarding Business
Associate's use and disclosure of Protected Health Information.
(1) Severability In the event any part or parts of this Agreement are held to be
unenforceable, the remainder of this Agreement will continue in effect. In addition, in the event a party
believes in good faith that any provision of this Agreement fails to comply with the then-current
requirements of the HIPAA Security and Privacy Rule, such party shall notify the other,party in writing
For a period of up to (30)thirty days, the parties shall address in good faith such concern and amend the
terms of'tbis Agreement, if'necessazy to bring it into compliance If, after such tbirty-day period, a party
believes in good faith that the Agreement fails to comply with the H1PAA Security and Privacy Rule,
then either party has the right to terminate upon written notice to the other party.
(m) Notices and Communications All instructions, notices, consents, demands, or other
communications required or contemplated by this Agreement shall be in writing and shall be delivered to
the Party at the address below:
Far Covered Entity: For Business Associate
(range County Housing,Human Rights
& Community Development Zahra Brooks
AKIN:Marlyn Valeiko 1000 Discovery Way,Apt 1017
300 W. Iryon Street Durham,NC 27703
Hillsborough NC,27278
(n) Strict compliance No failure by any Party to insist upon strict compliance with any
terms or provisions of this Agreement,to exercise any option, to enforce any right, or to seek any remedy
upon any default of any other Party shall affect, or constitute a waiver of, any Party's right to insist upon
such strict compliance, exercise that option, enforce that right, or seek that remedy with respect to that
default or any prior, or contemporaneous, or subsequent default No custom or practice of the Parties at
variance with any provisions of this Agreement shall affect, or constitute a waiver of,any Party's right to
demand strict compliance with all provisions of this Agreement.
(o) Governing Law Ihis Agreement shall be governed and construed in accordance with the
laws of the State of North Carolina except to the extent that North Carolina laws have been pre-empted by
HIPAA and without giving effect to principals of conflicts of law Jurisdiction shall be Orange County,
North Carolina, fox purposes of litigation resulting from disagreements ofthe Parties for purposes of this
Agreement and the Service Agteement(s).
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(p) E-Verify Employers and their subcontractors with 25 or more employees as defined in
Article 2 of Chapter 64 of the NC General Statutes must comply with E-Verify requirements to contract
with governmental units E-Verify is a Federal program operated by the United States Department of
Homeland Security and other federal agencies, or any successor or equivalent program used to verify the
work authorization of newly hired employees pursuant to federal law Where applicable, failure to
maintain compliance with the requirements of Article 2 of Chapter 64 of the North Carolina General
Statutes shall constitute breach of this Agreement H applicable, by executing this Agreement, Business
Associate affirms that they are in compliance with Article 3 of Chapter 64 if the North Carolina General
Statutes,
IN WIINESS WHE'REOP, the Parties have executed this Agreement as of the day and year written
above
rrT-nr. rr T..
CC ___DocuSigned by,T B�Ty -- DocuSignad_6y'_— -- r
Bye 0337ga467EGE477... S.�BC 7D01D010446....
Iitle: County Manager
Title: interpreter
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EXHIBIT A
COVERED ENTITY PRIVACY OFFICER CONTACT INFORMAIION
To report to Covered Entity any use or disclosure of Protected Health Information not in compliance with
the terms of'this Agreement that might be considered a privacy breach,Business Associate should contact
the Pxivacy Officer at the applicable entity.To report to Covered Entity any Security Incident (as defined
in the Agrcement),Business Associate should contact Carla Julian(919)245-2434,or the Security
Officer at The Orange County Health Department
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ORANGE COUNTY HEALTH DEPARTMENT
Conti acted Interpreters
Conditions of Contract Statement
Confidentiality
As a Contract Interpreter for Orange County Health Department (OCHD), I acknowledge that I may have
access to information that is confidential as mandated by state and federal law, HIPAA regulation and/or
Orange County policy. I recognize my legal obligation as a Contractor to maintain the confidentiality of
information about former and current recipients of OCHD services.
I understand that release of information determined to be confidential by law to unauthorized persons may
result in criminal prosecution. I further understand that the failure to maintain legally required confidentiality
of information constitutes "misconduct"within the meaning of the Orange County Personnel Ordinance and
may lead to disciplinary action, including termination of contract.
If'a question arises regarding whether a release of information may be public record vs. confidential client
information, I will seek assistance from an OCHD Clinic Manager
Title X Infoxmation Requirement
OCHD provides services solely on a voluntary basis. A client's acceptance of'service is not a prerequisite to
eligibility or receipt of a non-Title X service (family Planning).
As an OCHD Contract Interpreter, you may be subject to prosecution under f ederal law if you coerce or
endeavor to coerce any person to undergo an abortion or a sterilization procedure.
As an Interpreter, your responsibility is to convey the message from.the provider to the client to the best of
your ability, without prejudice or personal bias. If'you are present when an OCHD employee attempts to
coerce a person to undergo an abortion oar a sterilization procedure, discontinue interpreting, and report this to
the Clinic Manager
Public Health Activities in Emergency Situations
In order to fulfill the responsibilities of the department in emergency situations or in training, and due to our
limited number of bilingual staff, you maybe asked to work at emergency shelters or other locations
designated by the Health Director or emergency operations„ You may also be asked to participate in
emergency drills and exercises As a Contractor, you do have the right to decline any of these special
requests,.
I certify that I have read and understand the conditions stated above. I have had an opportunity to discuss the
conditions and requirements of my contract with a designated agency representative.
Contractor Name: zahra Brooks Date: 8/20/2015
DocuSigned by!
brbks 8/20/2015
Contractor Signature: Date:
DacuSigned by!
OCHD Representative: IL, Date: 8/23/2015
2FE2C29B947F40W...
DocuSign Envelope ID:5B6FF7D8-5B74-4BD3-BC2C-DDBAEB3C9E82
ATTACEMENT B
SCOPE OF WORK
Orange County Department of Social Services
Federal Tax Id. or SSN
Contract 4
A. CONTRACTOR INFORMATION
1 Contractor Agency Name:
2. If different from Contract Administrator Information in General Contract:
Address
Telephone Number: Fax Number: Email:
3. Name of Program (s): Interpreter Services
4. Status: ( ) Public ( j Private, Not for Profit (X)Private, For Profit
5, Contractor's Financial Reporting Year- July, 2015 .through_ June 30, 2016
B Explanation of Services to be provided and to whom (include SIS Service Code):
C Rate per unit of Service (define the unit):
l If Standard Fixed Rate, Maximum Allowable, (See Rates for Services Chart)
2, Negotiated County Rate.
$40.00/hour - Interpretation
D, Number of units to be provided:
E. Details of Billing process and Time Frames; The County will reimburse the Contractor
for,services described in this contract L:ip to the budgetary limits of the contract allotment.
The County will reimburse the Contractor at a rate of$40.00/hour for approved services
provided and travel at the cojM rate. For reimbursement the Contractor must submit the
Orange County De artment of Social Services Invoice for Payment of Inter retin
Services form to the Caunty staff at the time services are rendered. County staff will
verify the information sigLi the form and forward the form to the designated County
Administrator. The County will rcimburse the Contractor monthly upon receipt of a
complete and correctly filed report.
Contract-Scope of Wozk(06104) Page 1of 2
DocuSign Envelope ID:5B6FF7D8-5B74-4BD3-BC2C-DDBAEB3C9E82
Per hoax reimbursement will begin at the time the Contxactoz meets with County staff for
the appointment and ends when the Count staff and Contxactox contact is com feted.
The_xe will be_a_minimu_ni of 1 hour of service for an upointment. Mileage
reimbursement will be foi.round tri fp xom the Contractor's home ox work site to the
pxeairanged appointment site.
f. Area to be sei ved/D elivery site(s): Orange Count_
DocuSignad by,. DocuSigned by!
0337994NEGE477... - W�3 BC DU D910448....
(Siguaturc of County Authorized Person) (Signature of Contractor)
8/26/2015 8/20/2015
(Date Submitted) (Date Submitted)
Contiact-Scope of Work(06/04) Page 2of'2
DocuSign Envelope ID:5B6FF7D8-5B74-4BD3-BC2C-DDBAEB3C9E82
ATTACHMENT C
CERTIF'ICAIION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
Orange County Department of Social Services
L By execution of this Agreement the Contractor certifics that it will provide a drug-free
workplace by:
A publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing,possession or use of a controlled substance is prohibited in the Contractor's
workplace and specifying the actions that will be taken against employees for violation of
such prohibition;
B. Establishing a drug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2.) The Contractor's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that maybe imposed upon employees for drug abuse violations
occurring in the workplace;
C, Making it a requirement that each employee be engaged in the performance of the
agreement be given a copy of the statement required by paragraph (A);
D Notifying the employee in the statement required by paragraph(A) that, as a condition of
employment under the agreement, the employee will:
(1) Abide by the terms of the statement; and
(2)Notify the employer of any criminal drug statute conviction far a violation occurring
in the workplace no later than five days after such conviction,
E. Notifying the County within ten days after receiving notice under subparagraph (D)(2)
from an employee or otherwise receiving actual notice of such conviction;
F Taking one of'the following actions,within 30 days of receiving notice under
subparagraph (D)(2),with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an employee,up to and including
termination; or
(2.) Requiting such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health,
law enforcement, or other appropriate agency; and
Malang a good faith effort to continue to maintain a drug-free workplace through implementation
of paragraphs (A), (B), (C), (D), (E), and (F).
l ederal Certification-Drug-Fiee Workplace(06104) Page t of 2
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II. the site(s)for the petformance of work done in connection with the specific agreement are
listed below:
1 113 Mayo Street
(Street address)
Hillsborough, Orange,NC, 27278
(City, county, state, zip code)
2 _ 2501 Homestead Road _
(Street address)
Chapel Hill, Orange,NC, 27516
(City, county, state,zip code)
Contractor will inform the County of any additional sites for performance of'work under this
agreement.
False certification or violation of the certification shall be grounds for suspension of'payment,
suspension or termination of grants, of government-wide Federal suspension oz debarment
(Section 4 CFR Part 85, Section 85 615 and 86.620)
F DocuSigned by'
brbks interpreter
DO 10446...
�;rgnature Title
8/20/2015
Agency/Organization Date
(Certification signature should be same as Contract signature}
Federal Certification-Drug-Free Workplace(06104) Page 2 of 2
DocuSign Envelope ID:5B6FF7D8-5B74-4BD3-BC2C-DDBAEB3C9E82
ATTACHMENT D
CONFLICT OF INTEREST POLICY
Orange County Department of Social Services
Conflict of Inter est Defined:
A conflict of interest is defined as an actual or perceived interest by a(Contractor/staff
member/Board member) in an action that results in, or has the appearance of resulting in.,
personal, organizational, or professional gain. A conflict of interest occurs when an
employee/Contractor/Board member has a direct or fiduciary interest in another
relationship, A conflict of interest could include:
➢ Ownership with a member of the Board of Directors/Trustees or an employee
where one or the other has supervisory authority over the other or with a client
who receives services.
➢ Employment of or by a member of the Board of Directors/Trustees or an
employee where one or the other has supervisory authority over the other or
with a client who receives services
➢ Contractual relationship with a member of the Board of Directors/frustees or
an employee where one or the other has supervisory authority oven the other or
with a client who receives services.
➢ Cr editor,or debtor to a member of the Board of Directors/Trustees or an
employee where one or the other has supervisory authority over the other or
with a client who receives services
➢ Consultative or consumer relationship with a member of the Board of
Directors/Trustees or an employee where one or the other has supervisory
authority over the other or with a client who receives services„
the definition of conflict of interest includes any bias or the appearance of bias in a
decision-making process that would reflect a dual role played by a member of the
organization or group An example, for instance,might involve a person who is an
employee and a Board member, or a person who is an employee and who hires
fkn_ily members as consultants
Employee/ContractorlBoard Member Responsibilities:
It is in the interest of the organization,individual staff, and Board members to strengthen
trust and confidence in each other, to expedite resolution of problems, to mitigate the
effect and to minimize organizational and individual stress that can be caused by a
conflict of interest
Employees are to avoid any conflict of'intetest, even the appearance of a conflict of
interest. This organization serves the community as a whole rather than only serving a
special 'interest group The appearance of a conflict of interest can cause embarrassment
to the organization and,jeopardize the credibility of the organization. Any conflict of
interest,potential conflict of interest, or the appearance of a conflict of'interest is to be
reported to your supervisor immediately. Employees are to maintain independence and
objectivity with clients, the community, and organization. Employees are called to
Conflict of Interest Policy(06104) Page 1 of 2
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maintain a sense of fairness, civility, ethics and personal integrity even though law,
regulation, or custom does not require them
Acceptance of Gifts:
Employees,members of employee's immediate family, and members of the Board are
prohibited froxn accepting gifts,money or gratuities from the following:
a Persons receiving benefits or services from the organization;
b Any person or organization performing or seeking to perform services under
contract with the organization; and
c.. Persons who are otherwise in a position to benefit from the actions of any
employee of'the organization.
Employees may, with the prior written approval of their supexvisar, receive honoraria for
lectures and other such activities while on personal days, compensatory time, annual
leave,or leave without pay. If'the employee is acting in any official capacity,honoraria
received by an employee in connection with activities relating to employment with the
organization axe to be paid to the organization
NOTARIZED CONFLICT OF INTEREST POLICY
State of'North Carolina
County of'Orange
, certify that I have read the forgoing
information,understand it, and that no conflict of'interest exists in the execution of this
contract
- ��A k-,k
SijrQure
Sworn to and subscribed before me on the day of , 2015.
My Commission Expires:
ta4SignatAmuu and Seal)
CRYS AT L BELLES CC 6
NOTARY PUBLIC
ORANGE COUNTY
NORTH CAROLINA
Conflict of Interest Policy(06/04) Page 2 of 2
DocuSign Envelope ID:5B6FF7D8-5B74-4BD3-BC2C-DDBAEB3C9E82
Exhibit E
Zahra Brooks
1000 Discovery Way
Apt. 1017
Durham,NC 27703
To: Orange County Department of Social Services
Certification:
I certify that I do not have any overdue tax debts, as defined by N C.G.S. 105-243..1, at
the federal, State, or local level. I further understand that any person who makes a false
statement in violation of N,C.G.S. 143-62(b2) is guilty of a criminal offense punishable
as provided by N.0 G.S 143-34(b)
Sworn Statement:
I, being duly sworn, say that I am Zahr a Brooks; and that the foregoing certification is
true, accurate and complete to the best of'my knowledge and was made and subscribed by
me. I also acknowledge and understand that any misuse of State funds will be reported to
the appropriate authorities for fiuther action.
��.a
Sibiatule
Sworn to and subscribed before me on the da y of 2015
My Commission Expires:
( o
CRYSTAL BELLE COBLE
NOTARY PUBLIC
ORANGE COUNTY
NORTH CAROLINA