HomeMy WebLinkAboutR 2016-520 Health - UNC Faculty Physicians for services related to BCCCP program ORANGE COUNTY—CONTRACT CONTROL SHEET D
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: KatWjn Grant Contact Phone: 984-974-1274 [
Party/Vendor Address:211 Friday Center Drive City Chapel Hill State:NC Zip:27517 Department:Health Amount: $4,000V$�pose:
Services related to BCCCP program. Budget Codes 0412020-631010-7140 endor#21680 (N/A if new vendor) Vendor is a
BOCC consultant? Yes❑No® Contract Type: (C eck one)New❑ Renei ,'N Amendment ❑ Effective Date 7-1-16 Approved
by Board Yes❑Non Agenda Date: Title of Contract:UNC BCCCP Program.
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❑Nor-1 Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content:
Department Director's Signature: Date:
IT D ctor
(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; E] WC; E] Professional; E] Property; OR No Insurance Required E]. Hold
Contract pending receipt of Certificate of Insurance R. With incorporation of Insurance provisions as shown,this contract is approved
by the Risk Manager: C;
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Risk Manager's Signature: Date: 4
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Financial Services
This Contract is conditioned upon appropriation by t Board of Commissioners this fo�N s instrument has been pre-audited in the
before approval Yes❑No❑. If budget amendme s nec ,p
manner required by the Local Government Budget Fis C ntro ct:
Date:
Financial Services Director's Signature:
County Attorney
Approval by Board El (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approval by Manager(Most other contracts 1 0 as 0 ndalbove and Department ie Director approval only❑ (Under
$1,000). This contract has been re 1 w d an oved by the y
Date:
Attorney's Signature
County Manager
This contract has been reviewed and is approved by the County Manager Yes❑No❑.
This contract has been reviewed and is for signature by the Chair Yes❑No❑.
Date:
Manager's Signature:
Clerk to the Board ,20
Approved by BOCC on the_day of bmitted for Chair signature on the_day of
Date: 7
Clerk's Signature:
Revised March 2012