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2016-604-E Finance - Duke HomeCare & Hospice - Outside Agency Performance Agreement
DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2016, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and Duke HomeCare & Hospice, a not-for-profit corporation, located at 4321 Medical Park Drive, Suite 101, Durham,NC 27704 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Duke HomeCare&Hospice agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2016 to June 30,2017. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 1000. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $ 250. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 - June 30. Reports are due on January 13, April 14, and July 14 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services,upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default"), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider,the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten(10)business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers'or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A- Statutory State NC & Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability)required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.15 per hour. To the extent possible, Orange County recommends that Duke HomeCare & Hospice provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 County: Finance &Administrative Services Provider: Duke HomeCare&Hospice Orange County 4321 Medical Park Drive, Suite Post Office Box 8181 101 Hillsborough,NC 27278 Durham,NC 27704 16. E ntire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. 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 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and o b��a ,; eheProvider / ''� S or browtAAl 4 bbUbb9bAbUb4U1. 10/26/2016 , Date For and on aarunge County Government ttlA,ln,it, N wtt-rStUi 10/31/2016 L00379941375 .477.. Bonnie Hammersley, Coun t y Manager Date (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 ATTACHMENT "A" Orange County Certifications—FY 2016-17 Outside Agency Performance Agreement Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name,title,residential address;phone and email address and if possible,fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. DocuSigned1by: ,�,1,, I/a Star 1�v'ewlu Executive Di rector 10/26/2016 Certified by: itle: Date: DEGDC 5AGOD4C1... (Provider's Signature) (Duke HomeCare&Hospice) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 Exhibit A Provider's Outside AgencApplication MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Duke University Health System, Inc. d/b/a Duke Home Care& Hospice Applicant Organization's Physical Address: 4321 Medical Park Drive, Suite 101, Durham, NC 27704 Applicant Organization's Mailing Address: 4321 Medical Park Drive, Suite 101, Durham, NC 27704 Applicant Organization's Web Address: https://dhch.duhs.duke.edu Executive Director: Belle Starr Browning Telephone Number: 919.620.3853 E-Mail: starr.browning@duke.edu DUNS Number: (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) Project/Program Contact Information Project/Program Name: Duke Home Care & Hospice Project/Program Primary Contact and Title: Dale Horton Telephone Number: 919-479-0318 E-Mail: dale.hortonduke.edu c) Funding Request Identification Total Project/Program Cost: $13,864Total Amount of Funds Requested: $7,800.00 Proposed Use of Funds Requested (2-3 Line Maximum): Duke Hospice Bereavement Services will use the funds to offset the costs of providing care to grieving individuals in Chapel Hill, Carrboro and Orange County. We continue to offer our services at no cost to any individual in the area who requests our support. Please check all types, sources, and amounts of funding being requested. You must submit an application package for each funding source. *The Participating Jurisdiction reserves the right to fund projects from any funding source, subject to eligibility and funding constraints. CDBG Non-Construction (CH) $ Grant E Loan LI CDBG Construction (CH) E Grant Li Loan HOME CHDO (OC) pi Grant E Loan 0 HOME Other (OC) L Grant I Loan X Human Services: X Carrboro $3,800 X Chapel Hill $3,000 X Orange County $1,000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: Y),- : Director Date 4)&i, Signature: ( 2 2. - I 1) Boar" Chairperson Date Main Application 1/25/2016 12:06:09 PM H , r DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Month/Year) b) Agency's Purpose/Mission c) Types of Services the Agency Provides d) Agency's Experience with Similar Programs as the Funding Request e) Other Pertinent Agency Information (a.) 37 years in operation, Incorporated in 1979 (b.)The mission of the Duke Hospice Bereavement Services (DHBS) is to facilitate a safe and healing grief process for persons who are adjusting to a loss due to death. It is a direct clinical service outreach into the community for Duke HomeCare & Hospice. (c)Duke Hospice Bereavement Services (DHBS) support to grieving people. There are two service lines provided through DI-IBS: hospice support and community support. The hospice benefit requires that hospice services offer grief support and education to hospice family members and operate a program through which grieving family members of hospice patients can receive counseling, information and resources to assist them in coping with the death of a loved one. In addition to the hospice level of care, DUBS extends its support to the community by offering individual grief support, access to workshops and grief groups, education and resources to help any member of the community adjust to living life after the death of a loved one. Services to both program lines: • Grief support through individual counseling and grief group support • Community education available to any civic or religious group which requests that type of support • Crisis intervention after the sudden death in the work place • School based interventions including education and workshops for administrative staff, teachers, social workers, counselors • School based interventions including training of social workers and counselors to respond to grief in the school. • School based grief support groups with an emphasis on providing training and supervision for school social workers and counselors to feel better equipped to address symptoms of grief which may occur in schools. • Annual memorial services to commemorate people lost to death. These services are open to the community. • Annual Camp ReLEAF for children kindergarten through 8'1' grade. An annual overnight camp to assist children in adjusting to the death of a significant person and to develop coping skills to better understand and manage their own grief responses. • Family grief support groups to provide education to parents/guardians and children to enhance communication and understanding of the impact of grief on the family system. (d) Now in its 37th year, Duke Hospice (formally Triangle Hospice) was founded by a group of volunteers in 1979. During this span, it became one of the largest and foremost providers of hospice care in North Carolina. During the early 1990's these volunteers, led by former governor, the late Terry Sanford, raised $2 million to build a 6-bed Inpatient Care Main Application 1/25/2016 11 :36:35 AM Page 4 of 16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application MAIN APPLICATION Facility in the Meadowlands in Hillsborough, which provides 24-hour care for those hospice patients in psychosocial crisis, unmanageable pain and/or need for respite care. In 1995, with a gift from GlaxoWellcome, the Beard House, which is on the same I I-acre site, was transformed into the Unicorn Bereavement Center. Staffed with two full-time bereavement counselors and one part-time bereavement counselor, the UBC serves both hospice families and those in the community who have lost a loved one. Each year, more than nine multi- week support groups and workshops are held at the UBC. We provide medical, psychosocial, spiritual and bereavement care for terminally ill patients and families, regardless of ability to pay. Bereavement services are provided to anyone in the community, regardless of connection to hospice, through individual, family, and group sessions, as well as in the Chapel Hill-Carrboro and Orange County School Systems. 3. PROJECT/PROGRAM INFORMATION Agency& Program Name: Duke Home Care & Hospice As you complete your application, complete only those sections that pertain to the type of application you are submitting. The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: X Human Services (Main Application Only) Ii CDBG Non-Construction —(Main Application AND Part A) ▪ CDBG Construction — (Main Application AND Part A AND Part B) HOME CHDO Set-aside —(Main Application AND Part A) O HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: i Public Program Category Youth Adult Elderly Disabled ruu'le Housing(not elderly) Neighborhoods/Residents Education X X X Health and Nutrition Job Training X X X Sports and Arts Activities Pre-School Activities After-School Activities Mentoring X X — X Transportation Housing Other: Please specify grief counseling X X X Main Application 1/25/2016 11:36:35 AM Page 5 of 16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application MAIN APPLICATION Prooram/Proiect Description,(Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: See attached b) Summarize the program services proposed and how the program will address the chosen Town/County priority? c) Describe the local need or problem to be addressed in relation to the Consolidated Plan or other community priorities (i.e. Council/Board Goals). Cite local data to support the need for this program and the population being served. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. e) Who specifically will carry out the activities and in what location will they be carried out? f) Describe specifically the period over which the activities will be carried out, the frequency with which the activities will be carried out, and the frequency with which services will be delivered. Include an implementation timeline. g) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. i) Include any other pertinent information. Program/Project Information j) Complete the Target Population and Program Beneficiary Demographics Chart k) Complete the Schedule of Positions Chart for Program Staff I) Disclosure of Potential Conflicts of Interested must be signed m) Complete the Work Statement Chart to describe the work to be performed, and be sure to attach copies of all data collection tools that will be used to verify achievement of program goals and objectives. Describe who will be responsible for monitoring progress. Information to Complete j.) Target Population Complete the following tables to the best of your ability. Show numbers of participants and percentages, as applicable, in each category. Please indicate whether this project/program will serve: ri Persons E Households LI Units Program: Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 50 60 65 Female 63 96 103 Total 113 156 168 Of the females, how many are single- female Head of Households (Omit for Human Services) Main Application 1/25/2016 11:36:35 AM Page 6 of 16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application Page 5 — Program / Project Description (b) Programs: Duke Hospice Bereavement Services has a vibrant and active children's bereavement program which emphasizes the importance of recognizing the developmental consequences of death and grief during the early years. We have developed a workshop which targeted all school personnel who may have contact with children. The goal of this workshop was to provide education and resources to assist school personnel to better understand the impact of grief and loss on the cognitive, physical and emotional well-being of children. The Bereavement Center is located in Hillsborough and serves as a primary resource for grief support and education for both the Chapel Hill/Carrboro and Orange County School system. We receive regular calls from school personnel in both districts requesting support, resources, education and intervention for the children in their districts. (c) Town/county priority: Protect and Provide for a safe community (d) Population to be served. Duke Hospice Bereavement Services has been a leader in providing grief support and education in the Triangle Area and has partnered with local school systems to address the needs of grieving students in the school setting. For over 15 years we have consulted with and responded to requests for support in the local school systems and in the communities we serve. (e) Who specifically will carry out? The Bereavement Center staff consisting of 2.6 full time staff will provide the services indicated. The staff provides training to student interns who will also be available on a limited basis to provide these services. The primary location will be the Unicorn Bereavement Center located in Hillsborough. Additional sites will include any school in the districts serving student in Orange County as well as administrative offices of those districts and other gathering places which will accommodate the provision of services requested. (f) Describe period: Camp ReLEAF is an annual event and is next scheduled for April 29, 30 & May 1, 2016. It will be held at Camp New Hope. This schedule is followed as closely as possible each year after adjusting for holidays or religious events which may interfere with those periods of time. School based grief support groups are located at the requesting school site and will run for a total of 6 weeks. The frequency will be determined by the number of requests received. DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application Individual, group and family grief support is provided as needed and according to mutual developed goals established between the requesting person and the Duke Hospice Bereavement staff. Crisis intervention is available as requested. School consultation is available upon request. (g) Bulleted list of other agencies: • Chapel Hill-Carrboro and Orange County School System • Triangle Consortium for Suicide Prevention • Perinatal Loss Education Consortium • A Helping Hand • UNC Health System • Durham Coalition on Grief • S.O.S • Compassionate Friends • Other local non-profit organizations to meet the unmet needs of patients with limited resources. (h) Describe what would happen: Duke Hospice Bereavement Services provides the most comprehensive children's bereavement program in the area. The area likely to be most impacted by a reduction in funding would be our ability to respond to all of the requests for support services to the schools. We would continue to provide counselling and support to any child but would be challenged in our ability to take those services to the children; instead the parents/guardians would bear some of the burden of getting their children to the site where our services are offered. We would continue to seek funding from other sources to ensure our ability to reach children where they are and not increase the burden of seeking care during a time when families lives are in disarray due to the death of a significant family member. DocuSign Envelope ID:38357F45-0Fo1-474F-992F-A2000A42A3E2 [ A- CO[tiOUed Provider's Outside Agency Application MAIN APPLICATION African-American 15 14 15 ' ------ American Indian or Alaska Native 0 0 0 Asian 1 0 0 Caucasian 85 116 125 __ Native Hawaiian or other Pacific Islander 0 0 0 Other 12 16 28 „ Total 113 156 168 _ Of the above, how many Hispanic/Latino 1 2 2 . Of the above, how many non- Hinpanic/Lodno 112 154 106 Total 113 156 | 168 0-5 years 0 0 0 6-18 years 0 0 0 10-50 yea/s __ 3 _ 2 3 51-61 years 7 10 11 62+ years , 103 144 154 � Total 113 156 168 Durham City O , 0 0 Durham County 0 0 0 Carrboro 6 8 9 Chapel Hill 41 64 69 Chapel Hill Public Housing Residents Orange County 66 84 98 Raleigh 0 0 0 Wake County __ 0 0 0 Total 113 156 168 < 30%Area Median Income 31-50% Area Median Income 51-80% Area Median Income IIIIIIIIIIIIIII IMIIIIIMIIIIIIII > 80%Area Median Income Total 0 0 0 0 Elderly (Over 62) 103 144 154 Disabled (not elderly) Homeless People with HIV/Aids MEM Total 103 144 154 Main Application 1/25/2016 11:36:35 AM Page 7 of 16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application MAIN APPLICATION CDBG & HOME ONLY- Area Benett ActMties (Infrastructure and Public Facilities) Street Census Tract Block Group Total Persons #LMI Persons 2015 Area Median Family income Limits U.S. Department of Housing & Urban Development (HUD) 2015 Area Median Family Income Limits Effective March 15, 2015 Level person people people people people people people people 30% AMI $14,150 $16,200 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890 50% AMI $23,600 $27,000 $30,350 $33,700 $36,400 $39,100 $41,800 $44,500 80% AMI $37,750 $43,150 $48,550 $53,900 $58,250 $62,550 $66,850 $71,150 100% AMI $47,188 $53,938 $60,688 $67,375 $72,813 $78,188 $83,563 $88,937 115% AMI $54,266 $62,028 $69,791 $77,481 $83,734 $89,916 $96,097 $102,278 http://www.huduser.org/portal/datasets/il/i115/FY2015 IL nc.pdf Main Application 1/25/2016 11:36:35 AM Page 8 of 16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application MAIN APPLICATION k.) Schedule of Positions Please include program staff positions followed by volunteer positions; these financial figures should match the personnel figures in your Agency Comparative Budget Excel Form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). ifi!teoiiiiled;::,'f,.: 1001CPte:,.1';'!:',,,',. P6ijtiOij:TitiiiStalii.',:),'a,,,,,,4,,:,,,,,,,.4 ..:1,A111:/,,Yoligied,i.iniA''0,1V',:lii:;;I:i:,,,,fii,.. ,,,'4 , ,:lt. !4P,r,91.9.,c.:t.Pai Iiii$44,Iii'', ,,i(g,;),p,tiggpfill:;:1:2:.; i; 64iiiVii5,2,1,:ati.s!!.7,i, ligg,!::d'''',14i'i'iri'''''"Iiir•"''''1:::j'i ig,:i:Ii, 191,,1rL140'1.',"0.,' , '.1,!: . 7,4.1.:1'71.410i#401,!E 4li'f,4V :17F!:gliiiiiilkitii40146:f v ,i,,,;.,,,,,,,,,,,,,,i iv,.:ti,,t;:in,i.,.,,,,z:;,,.,,,,,,,,siffr,..4;'jrfP,j:,,,, ,iggQ1)4./t4A',Eilti:.,,iii#,;;;;,91. 1,0.,:#:::,':.:blzaiiipi');:it,:i.,,,,,111:,P,,;7,10.„.:CIPt.i';;1 rif,'114.1"ii0it ;4101010,:''. '?.'d'.'.'4';'.'''''51.'4' ''",14.g"0155:MMIRUP (H)11001t1T.i.:.,,;! Pitit'sgq.ARIAt.. See attached Exhibit A 1111 IIII 11111 II MI= . 111111 IIII 11111111111111 1 III" Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • ** Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours =Volunteer FTE 1,960 Main Application 1/25/2016 11 :36:35 AM Page 9 of 16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 I A- continued Provider's Outside Agency Application Dpopp40000044 4410ggPcn.0',Q1ji '''.4):V),,,4, 0,44,,:.,y,/,,,,,-,,.•;,, T,,,,,,,,,,,,,:%.,,,,A ,A,Mgir,:ol:Hafott4 ';::AfilIND110,00•13/,. glINffellIgi44.'i: '',:grATRIAMV,,.01‘. Apolpg,,,00144t: ,,OvtompzipoNodv,,g'', !.10,,:giogp,vgfara!,,,7_,4 .:,,,,to.,,,Agrotruf4,7,077,72, TJ'AY'sksize,1$444,411 ,.,,,,?knoomiou'llpii..fff :4gio,c,f0100,17:47,461 :!,,,,foifgfolo. ,04,00. ,:;tv,2,:moy.?1,40,ipamkopoN ilAll0f,„,6ffili* Otii11181046%0M OattflANNOPI tUffignatittAr%% INVIPC,494P").;-4°' AmoyANA:40kOn0 ISTOUNSolek ogilorgwitrogm,, $5:0160v45,01,0 ,3y,,oefrowisfopri 1,1504,040 gat .!'figlagiggfsigm.,..:.041v 110401Apptont,01 qlffeitatliOtx, .',3torntra,,,,g'siolAg , 114704044* Y, ,vwxj,togoNgto!..: '1605,gdgiggisigto5/,'. :i,ov,,,,Agestveissti: .::,:g;q:g$,wzopootp i, :,,e.vigeggtogm::: zoggoargogt CO LD 0 ri ‘-f 0 r-I (NJ tal m al ‘zr 0 (.1) N o 0 0 0 0 CJ if, L.r) iida.: tD ,.-1 1..n ,-1 0 Ln r rvi Li) u..) 0 N v-i oo o 0 0 0 Ln a 0, ri Lo. :?,.,„];,:,,,,,;,,,,,,,,,A,,,,,,..',,,teR;',,v,:.fzi SY) 0 0 v-I r-1 1.1) 1,0 0 0 0 T-I 1.,r) (N (JD 0 ,)-i' CNI rst 0 r-i r'•-• Kt Kt T-I c--I f,:;$1210:TMCSRatig0 .,: '0,12,2;0100,VVR, :AcaalakqtlpigYn 'TMONigagitatr:. 1°- LU U) bA E > Cl- U) 0 iT:';',1,44Ratg'016;q411,10: ..-. D 17 w cri w H < U „,Im ti) U co C ;.,/,,go,F,MM:Y;41,0Y30140, — < 1. H — ......, f,r) ..... ....... .4-.. O Nt i iii':,MA aq g,',,IZn,,,, H C). ___ = I- Z > U u-i "C;) = = tc:` v) _11 Lu 01 * 0 Z Z Kt (/) L )) CC ' u O * LL L uj u F' 7, n 0 = CC VCC I VCC) VCC) .ce o H 0 — u —, z z z z z a L.0 0 .- ..,,,, - 2 CG c7) ri) - - V) c;;C U "el 1.0:', .11 _ .< -,,— , ,‹ ";7,' = = 0 0 v) in Z v) _ ....... i__ ..-J ui Lii Li.) 4-+ < < X E .(t -, x ,2;. > w w 17- 9 u c — t$ L,, ,„,,;,,,,,i„,,,,,,,.„„,,,,,,,,,,,,,,,„,,,„„,,,.. .1,_ v .., U L...., LU Lu Cl C la-I — < a) ..,;,;,,;,,,I',,,•,,P,,,F,I",,',,,FiI"':,174,4'; I-_, CK CC D F._ cc cc F__ 0 cC > _ 0 < t: U. W 1.1.1 L.LI 4- _0 {..) , , :ggq:;:'.',V,I,1;?,:,:::1,,,,,,',. CK z z lo U 1,-) C) (.,) U V) ,,,,,,,,5',:1;N:1;:'21. 0, ,,, I— ._I (!.? I-u L!) '22 _I _I -.1 (f)., Z Z. 0 Z. a 1- U < < < ....1 > (..9 > > < < < a) .2)'. U U 0 1:3 (7) -(7). id W (7) C (.1.) 0 El! (.Z.-.) () < Ejc < E, L.,E, () c2 z z 0 < cc cc < 0 cc 0 -1:-._ ...., < z z G c,_ Z, cL, c). Z Z ',:',:f';'/; :ftr;i:':'' ''j'i.',:al'i':: 0 = ..-7,i 0 LU DDIccDO < I-LITZ3 = 0 n. •••'". DD -L1L1 ::)* * CI) < L) (....) L.L. mzzo_ o_ ZucL. CI: uuuv) v) (frouuu * U DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application MAIN APPLICATION I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: YES NO Ej X a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? El X b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? Ft X c) Current beneficiaries of the project/program for which funds are requested? El X d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature E, ecutive Director Date 01, Signature: --14/14.44 .._ t Boars Chairperson Date Main Application 1/25/2016 11 :36:35 AM Page 10 of 1 6 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application MAIN APPLICATION m.) Work Statement This form is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. • Program Activities should outline major activities the agency implements to accomplish its program goals. • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. SMART Goals • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (Please See Attached) Actual Estimated Projected 2014-2015 2015-2016 2016-2017 P"PRIMIRIF i` 1111 111111111111°111111'11 PRI Yr'AN Niql!!" 11',06)44 .4 (4' L A 4,"il 414,1 ;./ 0 1.40.44 r (1,04 rY/(/4^4,/, 0$0210)2,r2 liii Program Activity 1 Program Goal Performance Measures Program Results 111/rfr ''Ilthrol'iortIO'11010110PPITAW VfrifYi' f?fs';'/'1(191111,frrlYivvillikil511114 ,ot A, A 0,4 1 jSJ, WAN(4(11 ,(4w 222 14 A 0/, lA , ,IJAWfdrati J'6j6P 6,6J P1 ,J ' JI rJi 4J1,6 Program Activity 2 Program Goal Performance Measures Program Results z , Jo,rr,14 r, h,/,hagr, 11 ohJ'(,' /4'0/ 9 ) 011,111111144 Amp ?" ) '11 f" f.0 f ) Program Activity 3 Program Goal Performance Measures Program Results rz, yy,), MON 144 giVPdegt 4■M' yr/ern, pAilf 0/ ,v01.11,),A#1,Pflr,/M19 flOrfr eMrp4,/MN/ p'6,1 4 'JM MiMPOIM t gool '1108010 ,0Y, mOrq 40/0'6 p I01 $0,v. y !yr, 'e PdrA6'0 66 0,4 66,0 k A 0,,(//[44 ,f „ p P0, Program Activity 4 Program Goal Performance Measures Program Results prpOrperpftir tfrAffpfprtrip latymprorepill, frf#NPfepre t 1144 ktod,+a,i ) 6},g k4 40*kc;I ,Oraid4,f10(4110„0&41A,A4( ,)i(oNilo tiYi O'im 4W 6,1 N intgam m)i)mAxm AAA'0; A) 4.)A1 N fi.ek,i)A Program Activity 5 Program Goal Performance Measures Program Results Main Application 1/25/2016 11:36:35 AM Page 11 of 1 6 DocuSign Envelope ID:38357F45-0Fo1-474F-992F-A2000A42A3E2 [ A- CO[tiOUed Provider's Outside Agency Application Work Statement (Page 11) Goals: Duke Hospice Bereavement Services (DHBS) offers bereavement support to both hospice and community clients 1) DHBS will schedule 250 community adult client encounters in FY16 2) DHBS will schedule 30 community child/teen clients in FY16 3) DHBS will schedule 330 hospice adult client encounters in FY16 4) DHBS will schedule 30 hospice child/teen clients in FY16 5) Camp ReLEAF will provide an overnight camp experience for children K-8th grade 6) DHBS will provide grief education and support to local educational and civic organizations as requested Goal# Actual 14-15 estimated 15-16 Projected 16-17 1 277 175 150 2 24 30 30 3 446 440 450 4 38 42 45 5 1O= .334uftotal 1O= .334 of total 10= .334 of total 6 17 15 13 Performance measures for all of the listed activities will be through service evaluation requested at the time of the event or at the conclusion of a series of related events. Related events would be ongoing individual or group counseling. Goal 5 Camp ReLEAF: each camper provides feedback regarding likes and dislikes of camp activities and overall participation. Each activity scored well in different age groups. There are no numbers associated with the scoring of satisfaction. Parents provide feedback about their children's reported experience with approximately 30%of campers requesting to come back the next year. 31 campers out of 34 total campers completed a group evaluation with 96% responding favorably to the camp experience. Predominant responses from campers indicated the importance of meeting other children their age who had experience something similar which reduces the isolation, loneliness and sense of being different. Goal # 3 98Y6 satisfaction 97% 95Y6 100 refer services 100 refer services 95% refer services 4 95%satisfaction 96%satisfaction 95%satisfaction 98% refer services 100% refer services 95% refer services 6 94%satisfaction 95Y4 satisfaction 95% satisfaction 100% refer 10096refe/ 95% refer 'services DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 1/25/2016 11:36:35 AM Page 12 of 16 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 1 Fchtifitted Provider's Outside Agency Application AGENCY NAME: Duke Home Care &Hospice AdtUal,,),,,I[',,,"'; );),,i,liFEstirhated'N',:0'"e,Projeeted Freitent,ho,4 0001,„9,,,,0,,,,N,W44,%004'0,'{ 4 14401414444444'4,44,44,44,44$44,'VIC4444444,14,1,„410,r0441,i,lp 4044,4,4,44,4 4444414,U1IVINA:'44' PROGRAM REVENUE 2131415K'', 01'1201516141'''''l'','"4,1'201617'''''''";',14'''''HiChange Private Donations $ 344,833 $ 467,200 $ 467,200 0% Program Generated Revenue (fees) $10,319,858 $11,008,000 $11,251,000 2% ., ... flAfp..,,,',IfigOolliplort: 1,„;,,Fro4tqo, ,Ttr:-01,,,,,i,"'"q14NIAiri1-4„"e"-,l',i,,,,$"1,11;Aor'il,,,,r,p,i,opri,, A,r,..11r,, ,, 116p,i'dtkt'64k''S4,1,kt6''' '.64041,i'14",,,Ifp,,p,Ikk,,k40,4,k16; Local Government Grants: ',ZiArfigNiWolli SilkteiNS,,,",,Olh"41011010111eitili Ne,N,,,ANiligirt Orange County $ 1,000 $ 1,000 $ 1,000 0% Town of Chapel Hill $ 3,000 $ 3,000 $ 3,000 0% Town of Carrboro $ 3,800 $ 3,800 $ 3,800 0%. Other Local: 0 .„ Other Local: 0 Other Local: 0 If more than 3 sources,please 'fl ''''''"'g,',J4jr i'1(i■I,f'6 ql. , i ,A'1,1,r. .,1 1,41 " 1, 1 A,,,,.0 ,H.1'„, i', , 4 1t-Op',,ll,/l44 444; 1 44 41 01 li, ,,, .p ri''1 .• 1 11,:;,,V,,4i k q/401114 lik 9'fi'l',,' k6t1,1,4,01 k' provide a separate list. i .1,',','lig ip,.,1'•:,.411,4„!411,4 1 .!,■,b,,1 ,,,,,,,..,11,40 ,±,Ai;,0,,,,Ii.' 4.Vorviii,,,'11',tl,;',.■,,3 ,i 1V4''14'4141114-1M tr '',',,6'6i'o PC■ I 4 If 1,1;,, 616'.6 li41 001)Y,0'j''$ .1.10("f,'.FT"'",1,7,,',ir,q''Ill 4"fir,,F1)q',:'ll'ijifi;,l'[?P'',III!ihil'1,1110'114 Non-Local Government Grants r?,,: ,„g 1 1 1, vt„,5,$;,1',, ,,,, 4,4,14i L,„,,f,,; ,,,„ ok k;,,,i,,[k ,i,;,r,,n■kg i,',„ ..4 ,''44'16, , '„,,,,'61,114''0 6'0' k",k,,[44$1,,gd''61'11,k1 Ii1144• Triangle United Way 0 State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 $11KIIMININSItIONNISINItt liNIVOMNSI OSIVIONOMNN Miscellaneous/Other Revenue 0 Please list 3 largest Miscellanous sources: 1;,..4,tri%% ,,ifi,,,, :„w,;,1,IJ ,'Ii/'14,{1,1,/,I,',4,11I1 $ 1', 11.411/1.0i 11,,,I,,,,, ,i,,,,,,,, ,,,,,..,,) . 1,!1.4,1.,404:11,,,,,Ali‘riktg,/, ):,,,, twoi,!,', $ - liii,41!'°,,41:;0 ii.'',) ',P01.41,-'',, I .0,0 1,1'1 01 filli iii,i il,„1,4'.f1.1.1 $ ,I. 0. lc,,°J.1,, .,,g..;d,4 kl,',k 4, vi kdlotti '0.1 ' lik r '4,6, A hl'• 1 1.. i'w,'141 4 ill 4,I ,1'164t 16 1,p Y,i.44.',,U1,■,11!,,,,,',,,,f:;!,"y,''VI,j„I','■, t I4''''' 44'■ 411 k..,Y',BE',,o'4;.,' , .. Total Program Revenue $10,672,491 $11,483,000 $11,726,000 _ 2% ,,t4,1114191;41,,11'1141 'Ili 1131',11 1,:i 114 lo,q..,4,K li gr/iVii itty"P)Ilvotti 11,41,11$1 PROGRAM EXPENSES 1.4!14) 1,1„,.,,t,,,),i,,:. 4,4,•'1 i 41: 4,"1'4r11p1 f'I,fl 4 Pla'SP 44 ,1,444 t44.'p'4fr'"ii A., N Iv fri.0 o(400.74.0441A A,1144. IY .1.,,,,.'.1',',',',,61,:1.1,,.,14,1.40.,tr,A11411441 0, 44414,A,.,,'.4 6R04, Compensation $ 5,344,986 $ 5,723,000 $ 5,927,000 4% Rent& Utilities $ 233,663 $ 243,009 $ 252,730 4% Supplies & Equipment $ 1,184,951 $ 1,208,000 $ 1,284,000 6% Travel &Training $ 166,535 $ 173,196 $ 180,124 4% Other Expenses: $ 4,090,343 $ 4,170,794 $ 4,237,146 2% Please list 3 largest"Other Expenses": ,,„,,,,%,113,„%%%,1%,,•01%1%, 'f64,4664 y 44:k 11.44444444414'q 444444,A4441,44,Nif41'444, 4y444P4N4,444/44444.044,44'4141 44,,4 $ _ Y.'0"I'd,,q,021','Y''.:14 NI.■'.:/'NI L'.i','4°4 41'lfAr4,1;,.:",,Or•.;`,',01: ',',4,',V1k6,141'4'6-teolii'"'",iwor', "4","1"'40,,,,',"■Phr(try'01f1,1', (4;4',F',1i116k1f1A6'1',1144:. kktY,14,4',#114.140/6Cr ''I'f,A6fkii,IMP,V161'''W6110.0 40'14c,k1'"?6416'616A?,1 , $ - 464'444.0i40114 6,1,60k.1114p1414114111/11144,411411111 11114/1"0.44411011404r11°10 11I44111411.414111114'41111 '11111"04144N114,1j1411f11 ;111141111111414414141/1141141 1441131011410,4440440 4141141,1444114444414414141 $ - 1144:41,111111154:1;04414414441 41411,141114:11'114154104141141 0141140641$110.4.01110 P1111410'1114'':11.14ti1C°41' 1141":1'11T't1!1•141111114135,144 V11111111117411111P1111111111144 (M110n14,4114;0$14111111 11411144111Vri114.154'1114411111 Total Program Expenses $11,020,478 $11,518,000 $11,881,000 _ 3% \ $ (347,987)1 $ (35,000)1 $ (155,000)1 -343(Yol ,,. t 1 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application MAIN APPLICATION b.) Program Budget Detail What is the cost to deliver your project/program? List each project/program element in the table below, including the cost of each element, the quantity and unit of measure, and the subtotal for each element. Where necessary, allocate costs to the use of shared space, vehicles or equipment. Exam S le Program: Creditia,u7selingClassu, ,,,(, ormfr....v r/Tr ffir i ii,,.,Ft Kim,r,,iiin r!fiffk iri,mu,of Am 1 gi I`''l'''s rifititirlfilltili;)110011t0'4414011/6j'1101117/0711"00 41,rir,fi A III ill 1110"Ifil'ilit th 0, 1 ;/4 ':ii'401:16410 trialik'2"' al )iiipq '(iirl `1F l2 ,'; 2 fi':0 I 1; 4 iiiiilit di If II)idtaild/j iididil ititi 44 i llik It it s Jidad ts4 h Ar A PA A 0/IA/ , Credit Counseling Teacher–in class $25 96 hours (8 hrs/mth x 12 months) $2,400 Credit Counseling Teacher—class prep $25 48 hours (4hrs/mth x 12 mths) $1,200 Credit Counselor—one-on-one $20 120 hours (10 hrs/mth x12 mths $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 Complete the table below for the proiect/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Duke HomeCare & Hospice ,, .1,,,,,,, §,frp 9 ,ifer,„o, rtrik,,,14 lay, ,, Nrvitawir 4. la .,, ,..1,-ot 4 1 1'4''' 4,' / fq i),,, ,, lo 1 i 1 g ,fA ' A i) i /I . , , .w , IOW,7 1 PiVi'11 4 la f f -117 ' . /111 rrrtit"11/1121:91"/Pwl till' gi,'12 /ollablediri, 4.,ii, . ,,,„,,,,,, 3,,, ,,,,,,, ,,,,, ,, „ ,,i, , School Grief Group $125 session 6 $750 Staff Supervision/Training $150/6 1 $150 sessions Mileage 24 sessions 6 $144 Camp ReLEAF— 13 students $340/Student 13 $4420 Counseling for 30 children $30/child 30 $900 Counseling for 250 Adults $30/Adult 250 $7500 Total $13,864 c.) Cost per Unit 4 111174 ri, 4,rk ,,,,4;,,, 014); i),Iffi Toifir,4',,,, v 1 , :iii, A, A A, ,..,,J A„ , ,,, A„ , i i, ■„, , Total Cost of Program $11,020,478 $11,518,000 $11,8817000 Total # of Units $53,931 $57,183 $58,775 Cost Per Unit $204.34 $201,42 $20214 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 1/25/2016 11:36:35 AM Page 14 of 1 6 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 t A- continued Provider's Outside Agency Application MAIN APPLICATION d.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017. Submit operating budget in your own format. Do not include funds that have been applied for but not yet awarded: If the total revenue is not the same amount as the budget for any fiscal year, please attach a statement explaining the deficit or surplus. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 1/25/2016 11 :36:35 AM Page 1 5 of 1 6 Au-dE8 DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42ik3E2 1 thtinued'—"— Provider's Outside Agency Application AGENCY NAME: Duke Home Care &Hospice T'041,Aetta 14Est.Mate .; Projected, v Percent..„:1,0,,,,,i1,„66,,0, .1 ,:f4, ;;, ,,:,,i8.,:..,;...,',..,24$1,A,::., ;;.,t$,,,,,•efik'6,0',,,,!;"], PROGRAM REVENUE iO4'.12014415,""Iro."'"6" '66gr'),`"2015166606V 66606 "I P7:11 ij,,,'41"' V.,;,'", Private Donations $ 344,833 $ 467,200 $ 467,200 0% Program Generated Revenue(fees) .. $10,319,858 $11,008,000 $11,251,000 , 2% l'I'''''',10;111111101,41illION.',ii•,iti'liagt01,P#,),1illir PATIVIRfailffillil Viiirlikt440,40'0060ti01,0:1 061616•"i6:'06166;P0,7,,,VIT'40,gairkpl:iithj7),0'olig,41,41:M.!,,,ui,'01.A'i4,ree',4,i1 1[41 VOA 3liea.,00014,04,1tAqil Local Government Grants: 1441,f0gL1644,14,,,'gi'dg,tikm'i'fii Narodootagito4.lo do,lif,,,,,,,44.14,6,,,m,,,,o,N. Orange County $ 1,000 $ 1,000 $ 1,000 0% Town of Chapel Hill $ 3,000 $ 3,000 $ 3,000 0% Town of Carrboro $ 3,800 $ 3,800 $ 3,800 0% Other Local: 0 Other Local: 0 Other Local: 0 0;, ,ii'le■t4i I r, -PV41 llit'tiq r 1,';;I'l,i.4' If more than 3 sources,please 7,y,t,.,,,,,,,i ir!,..,..,k4,1.,,,,,,, {th...1 .th,,','Ii.',r 11.411: 11:('',',',Y f ',,.1::Ii''',IP''1,!'f' l't l' 5 ': 4:,4',d!::,:! :l,,„ provide a separate list. ), 'If 11 61 I ' ,,,;.6'6,' , 0,64 ...6,,1' 6!■1 .„1),...:F , A ;.:1,fit■,,,I,',..!.f, 1, ; .„,,6'ti.,;.),Ft.,:..,,,',",:..,..!.',1,,,,.,!*, .i„.i ..11 ..‘,..6ini1.1.4,, *iv i''''.:1.6111P 01 .'.''151 ';',',1h.f lti,1111.14 Aiw:i16..NR.4.,'''',..,1,1,!'wo,i,',...:o''.,;',:1,041.): .r.,. 0., Non-Local Government Grants Triangle United Way 0 State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 ' ISNININNORIS iliVaggliell 8111211110111 INIIIIIIIMININE Miscellaneous/Other Revenue 0 ,,, ,i„,.,,,,,, ...,,,,.,,,,,,,,4,11,,,,1140,,,0 4".0Lp,P / Al , ■l',1 i ',e '' Please list 3 largest Miscellanous sources: f nw $ - i'l.i0ry„l,;;p:1a,,i.ia,,i 0 h.a (44 a1N r'::, $ .. ;a!,1.,,lk :1:.,,,.Nk4.4..,,.,f1",,,",:,14.114,9'■0;.:16r„, 1 Total Program Revenue $10,672,491 $11,483,000 $11,726,000 2,,,, PROGRAM EXPENSES ,J1,0t1..1",1 •I.0'4 P I01°1,.1;'1,,.iI„i f ril.iPI,,i 1'$.4 r,v1'0,'rVrittafi0torPHIRloilIs::‘,.pi1t4 i o,,i,,i,:f plll'.4,i,,A gA0.d., :,■1 , L !..,., ,..., ,.11,, Compensation $ 5,344,986 $ 5,723,000 $ 5,927,000 4% Rent& Utilities $ 233,663 $ 243,009 $ 252,730 4% Supplies &Equipment $ 1,184,951 $ 1,208,000 $ 1,284,000 6% Travel &Training $ 166,535 $ 173,196 $ 180,124 4% Other Expenses: $ 4,090,343 $ 4,170,794 $ 4,237,146 2% Please list 3 largest"Other Expenses: "P:140, Vii9P01;0,101,1.01A1A!°",1 14111.ttagaaaamogai.aaa:Tataavgaticarar:,at aa,:05,11..!ia.ANa0aaaaarailawai goy:aaalfa0avaaaaaa„OR taaaa,,a4aaaaao.aaaaraimaaa aJaaaaaaaaaaaataafaRaaaava,a, 1 ,.,a , ,: :: ,:::,:::: $ ,,,,aaaaataaaaaavadv„a4a;aa;araaaaatiolil a,,aaaaR ataVv,,:far4favatRia0: laaaa,ata04,41aaaalliaaaa, ' '''46'''Y'''"'"*.'4"a''faft'ada',.'"'''ag''''',4‘floaal:P 4'[511,,,aala,aafe:aaaaaapia,a4k aaaaa laalata:1 ia,,aaa a - ,i ';',"a,fi'afa,,I4V2.51.:111'.;N4F .,i'?„rataapaMagali,,,allalra at',,,,aaaaaar„Mafaaaa4laaaaaal gaailaaaa'agaaaa'aaaaa' $ '' I'llifAhjr,:jaNffi''',/41411' ',.';';'),'1:69'/,'',MA:41,,,",1.9"lon.al,..aa'1,aaasiaataapaaam iil'agiAIPIPParaala,Ca'aag $ aallid'ai.'llierrq:',7aanaaa',.AaPaaaaali'a4alaaial''olaaa. ',aailaaaaaataAa.44,aoarala,qmiariaaaiNr,r0i,a.adaaa'aaa - ;.r'l:'''','tl,''''4',Ik'I'','',16a',,'1!'',''','-'5,I,I,I,''''''','Jlf'a'k',11$1''''''''ii'',,';'1,',H111,aali.j':;i1,1-:','''',!fria.1,1!,ii, '''■,iail;:','','''1',n' 'll64-,a,!alltal,t111,,P;;;14,424'''''',,la Total Program Expenses $11,020,478 $11,518,000 $11,881,000 3% $ (347,987)1 $ (35,000)[ $ (155,000)1 -343% 1 '\, DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Duke HomeCare&Hospice Funding Award: $1,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Program Support Services 1,000 Program Services For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes below,by June 30,2016. • Provide bereavement support to both hospice and community clients. • Camp ReLEAF—overnighth camp experience for K-8t"grade Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Schedule community adult client encounters 250 Schedule community child/teen clients 30 Schedule hospice adult client encounters 330 Children report satisfaction in child's experience at Camp ReLEAF 90% DocuSigned by: b Star browtAA.KA Executive Director 10/26/2016 Certified by: BEfia&595A5.084G1_ Title: Date: (Provider's Signature) DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 DUKEUNI-01 FAROOQUINK AAcoR If)" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `••-- 9/22/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME:ME: W s Towers Watson Certificate Center N Willis of North Carolina,Inc. PHONE (877)945-7378 FAx 888 467-2378 c/o 26 Century Blvd (A/C,No,Ext): ) (NC,No): ( ) P.O. Box 305191 ADDRESS:certificates @willis.com Nashville,TN 37230-5191 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Duke University Risk Management Trust Fund B1512 INSURED INSURER B:Durham Casualty Company LTD-Bermuda C6616 Duke University INSURER C: Attn Chris Boroski PO Box 104143 INSURER D: Durham,NC 27708 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSD SUBR POLICY EFF POLICY EXP VD POLICY NUMBER W LIMITS (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS-MADE X OCCUR X GL-DURMRA 01/01/2016 01/01/2017 DAMAISGE TO RENTED 0 PREMES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Professional Liab. 17 PL 1027-P 07/01/2016 07/01/2017 Occ: $1,000,000/Agg: 3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) THIS CERTIFICATE VOIDS AND REPLACES PREVIOUSLY ISSUED CERTIFICATE DATED:9/20/2016. With respects to Policy No. 17 PL 1027-P,Named Insured includes:Duke University Health System. Additional Insured: Town of Chapel Hill. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Town of Chapel Hill 405 MLK Jr.Boulevard (Chapel Hill,NC 27514 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD