HomeMy WebLinkAboutR 2016-557 Health - UNC Dept. of Family Medicine - Medical Director services 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: Kathryn Grant Contact Phone: 984-974-1274
Party/Vendor Address:211 Friday Center Drive City ghqpel Hill State:NC Zip:27517 Department:Health Amount: $145,416
Purpose:Medical Director Services Budget Code(s)%L0414020-630000-71400/71403/71406/71409/71414/714-16 Vendor#21243 (N/A
if new vendor) Vendor is a BOCC consultant? Yes❑No® Contract Type:�eckvffe)Nev-❑ Irenewa Amendment ❑
Effective Date 7-1-16 Approved by Board Yes❑No❑ Agenda Date: Title of Contract:Medical Director
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:
Department Director's Signature: 'Uh- Date: �� �-
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 shown,this contract is approved
by the Risk Manager:
Risk Manager's Signature: Date:
Financial Services
This Contract is conditioned upon appropriation by Bo d of Co issioners Yes❑No❑. A budget amendment is necessary
before approval Yes❑No❑. If budget amendme s ne ,p ase attach to this form. This instrument has been pre-audited in the
manner required by the Local Government Budget n Fi " 1 ontr Act:
Financial Services Director's Signature: Date: `O 6
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 by Mana er (Most other contracts$1,000 and above). Department Director approval only❑ (Under
$1,000). This contract has be n r vie d approved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date: tJot i
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❑.
Manager's Signature: Date:
Clerk to the Board
Approved by BOCC on the day of 20 . Sub 'tted for Chair signature on the day of 120
Clerk's Signature: Date:
Revised March 2012