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2018-413-E Finance - Duke Home and Hospice Care outside agency agreement
DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2018, ( "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 "). 1VTjll1011.Y.` sIIII Im I 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, 2018 to June 30, 2019. 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 $1,115. 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 $ 278.75. 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 712018 Page I of 9 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 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. £ 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 11, April 12, and July 12 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 Page 2 of 9 Rev. 7118 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 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 parry 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 • Worker's Compensation • Commercial General Liability • Automobile Liability • Professional Liability MINIMUM REQUIRED COVERAGE Limits for Coverage A - Statutory State NC & Coverage B - Employers Liability $500,000 each accident, disease policy limit and disease each employee $1,000,000 Each Occurrence $2,000,000 Aggregate $500,000 Combined Single Limit $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 Page 3 of 9 Rev. 7118 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 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 Non - 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 $ 14.25 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 Page 4 of 9 Rev. 7118 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 County: Finance & Administrative Services Orange County Post Office Box 8181 Hillsborough, NC 27278 Provider: Duke HomeCare & Hospice 4321 Medical Park Drive, Suite 101 Durham, NC 27704 16. Entire 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 a I o signed by: Provider t,�tln. (a& b28n11aoOF104BB... For E6Q cuSigned by: r :'ounty Government Nwmt'yi 03799d6755E477... Bonnie Hammersley, County Manager (Duke HomeCare & Hospice) Orange County Outside Agency Performance Agreement Rev. 7118 8/14/2018 Date 8/14/2018 Date Page S of 9 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Duke University Health System, Inc. d /bla Duke HomeCare & 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: Kevin R. Carter, Director Telephone Number: 919.620.3853 E -Mail: kevin.carter@duke.edu Tax ID Number: 56- 2070036 b) Funding Request List all FY18 -19 Human Services (HS) Funding Being Requested — For All Programs) and the Proposed Use of Funds (2 -3 lines or less) Program Carrboro Chapel Hill - HS Orange County-HS Total HS Dube HomeCare & Hospice $3,900 $3,200 $1,100 $8,300 Totals $3,900 $3,200 $1,200 $8,300 c) 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: �. Director Signature: Board Chairperson I I -I Date Date AGENCY INFORMATION 1/19/2018 12:42:41 PM Page 1 of 11 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ x a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ x b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? x c) Current beneficiaries of the program for which funds are being requested? ❑ 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. NON - DISCRIMINATION Provider agrees as -part of consideration of the granting of funds by funding agencies to 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, gender identitylexpression, 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. To the best of my knowledge and belief all of the above information is true and current. acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of anv Grant awarded. Signature: t / \ L Director Date Signature; U{�' r�t L t- 2 � -/t Board thairperson Date AGENCY INFORMATION 1119/2018 12:42:41 PM Page 2 of 1 1 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): 1979 b) Agency's Purpose /Mission (no more than a few sentences): 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) Types of Services the Agency Provides (bullet format): Duke Hospice Bereavement Services provides (DHBS) support to grieving people. There are two service lines provided through DHBS; hospice bereavement support and community bereavement 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 include: • 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 ReLEAP for children kindergarten through 8"' 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. Agency Information 1/1912018 12:42:41 PM Page 3 o f 1 1 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION d) Agency's History with Providing These Services: Now in its 39th 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 fonner governor, the late `ferry Sanford, raised $2 million to build a 6 -bed Inpatient Care 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 11 -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. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director? Are there new initiatives ?) Our Executive Director retired in November 2017 and Kevin Carter is serving as Director while a national search is being conducted to replace Belle Starr Browning. f) Schedule of Positions (For Entire Agency) (see attached) • Full Time Equivalent (FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 1,920 # of FTE - Full -Time Paid Positions: 72.8 # of FTE - Paid Part -Time Positions: 6.40 # of Volunteers: 225 # of FTE - Volunteers: n/a g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes /No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? No Agency Information 1/19/2018 12:42:41 PM P a g e A of III DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 0 0 CL 0 -a EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION a c ra a ro _u y a a p cc = d cc a W v a cc is 0 F- v u a � a o. CL N LA 0 N N +,y E. H w V1 E [O to Q L a 0 r rn m n cr N O O rr, �+ Ln Ln rn Ln oc rn O 0 c--i O Lf' Lr, ri N O rn iy tz C71 m O o O O -i ri ri Ln r- X N 0 Lr 0 Ll1 0 ri ri O Ln N C] crl n'1 -p LD rq 0 ur O ri 0� O Lr1 0 1`,� N O rl r, 0 N 0 N r- N �o G" r1i 1P 0 ❑ Of x 0 Q 0 0 v 0 Lu cr- LLJ ❑ w w _ uj H ❑ Q 2 � < w U w Ui U Z su L tJ Q Q ++ h ¢ J V U U U — - >_ cQ z z Q w w Of 0 �J Z LL) w LLJ T d Ln d ''`� 2 w er wy, Ln cn � w LLJ � ❑ �- Q w Q Ln 2 2 D D Z L!'F In - O° O U v7 J z w w �J1 ° 06 Q —> O L i> = z N � w Q LzrJ �L��F- aQm° <Uz ¢ �� z 0l Uu LLJ 1- = o =� w 0 cc�< U n❑ Q Y, w V a w w> 7> oe < D m❑ 4¢} o a= U 0 0 0= oc U O m cc w w z ,� u U U U u V) z u L!7 c s u a U O cc ct cn L/1 NZ J J CE� % Q kD -J Vr z " .1 .-f J �: 3 L w L LLJ LLJ J J J Z z a a a z z 2i V Z Z U z a Q< a Q J w l7 > C7 0< <L Q Q u v ❑� �n cc LLJ � w -1 ca U U _ U ¢ F- Q d G U U U H o 0 >> 0 D <� z z z a-< z z,'V) o= CL e< DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION If no, please explain. Duke approved a minimum wage of $13.00 in 2017 and approved a minimum wage to be $15 beginning 2019. h) Agency Budget i. Is your agency currently receiving and/or requesting other (non -Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) Yes If yes, please list below: Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY17 -18 FY18 -19 Source Award Request Duke HomeCare & Hospice $3,800 $3,900 Town of Carrboro Duke HomeCare & Hospice $3,000 $3,200 Town of Chapel Hill *Add rows or attach additional page, if needed. Agency Information 2/19/2018 8:44 :27 AM Page 5 of 11 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION rFr IS'-19 Application Page 5 — Program / Project Description (c) 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. (d) 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. (e) Town/county priority: Protect and Provide for a safe community (f) 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. (g) Who specifically will carry out? The Bereavement Center staff consisting of 2.88 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 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 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. (h) Describe period: Camp ReLEAF is an annual event and is next scheduled for April 28 — 30, 2017. 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. During the school year 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 detennined by the number of requests received. 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 throughout the year. (i) Why is funding a good investment? • Death touches the lives of young people far more frequently than most of us would like to admit. • US Census Bureau stats — 5% by 16; 11% by 20 90% of HS Students say they have experienced the death of a significant person in their life • 40% will experience the death of a peer. 20% will have witnessed a death. • Impact is widespread and not contained to a specific period of time. Grief is a multi- dimensional experience Developmental in nature — change in understanding and experience. Impacts learning, behavior, and development. Our work supports school personnel are in a unique position to interact with children who are challenged to meet educational objectives while trying to negotiate the very difficult emotional terrain in adjusting to the death of a family member or friend. • Many feel unprepared to respond to the needs of grieving students. The 2012 Study by AFT and NY Life revealed: DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION • 691%0 of classroom teachers (almost 7 in 10) have a student who lost someone close to them in past year • Only 7% of those teachers had ever received Bereavement Training and only 3% said their school or district offers it. Of the 7% who had training, 46% sought it out themselves • Only I% of teachers received bereavement training as part of their coursework in college or graduate school • 63% said insufficient training and professional development are the primary things that hinders them from supporting grieving students. • Still "taboo" topics. Don't deny the reality of death, but we often deny the grief and the powerlessness that accompanies death. Bereaved can be under supported, which adds to the negative emotional impact of loss. 0) 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 counseling 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. W Other pertinent information: INAinimizing change in a child's lire will often lead to a better outcome, but change is inevitable when an integral member of the family dies. Death can have a ripple effect and mourning the secondary losses can become an important part of the grieving process. These losses can be numerous and can continue for a child's lifetinie A significant loss creates changes in relationship both within the family and beyond. ilSourrlirrg family members may be unavailable to the child in the same way and thus the child "looses" them in a way too. These changes effect the relationships within the fancily, and people outside the family may also act differently. The child's friends may act differently or the child may seek out other friends or peer groups as a result of the loss. There can be major lifestyle changes with a death. if the deceased contributed to the family's finances, there can be significant financial implications. Some children will need to move, which could involve the loss of not only their home but also perhaps the school they were in, the neighbors they left behind, etc. The child's extracurricular activities may no longer be possible clue to financial or logistical reasons DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION (one parent can only do so much). Child is likely to have new responsibilities at Dome and can be resentful about this. A death may lead to a change in the child's plans for the future. Perhaps, after a parent's death, a teen may not be able to afford to attend his or her college of choice, or may not have the help with college applications that the deceased parent would have provided. And as previously discussed, grieving children of all ages may experience a decreased sense of security and safety, which can be experienced as another loss. Duke Bereavement Services cannot meet all of these needs. It is our hope to provide as much support as possible to families to support them as they learn to cope with change brought about by loss. Additionally, we strive to provide educational opportunities for school personnel to assist them in learning about the unique challenges brought about by loss and support there in developing successful interventions for meeting the children's needs while in the school setting. DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION ii. Submit your agency's budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues • Private Donations • Program Generated Revenue • Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG /HOME /etc.) • Private Foundation Grants • Other Revenue _.±_._Expenritures • Compensation • Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes /No No Please provide a brief explanation for Surplus or Deficit, and significant changes. iv. What is your agency's fiscal year? July 1, 2018 thru June 30, 2019 (Example: July 1, 2016 through June 30, 2017) Agency Information 1119/2018 12 :42:41 PM page, 6 of 11 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Duke Hospice AGENCY REVENUE Private Donations Agency Generated Revenue (fees) Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Granville County Other Government Grants Triangle United Way State Government Federal Government (CDBG/HOME /etc.) Private Foundation Grants Other Revenue Total Agency Revenue AGENCY EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Total Agency Expenses SURPLUS /(DEFICIT) FOR PERIOD: 1 $ 24,1491$- 39,492 1 $ 24,000 -39% FY 2015 -16 Comparative Agency Budget Revised 9/2912014 Actual 2016 -17 Estimated 2017 -18 Projected 2018 19 Percent Change $ 480,719 $ 540,100 $ 539,800 0% $ 12,109,420 $ 12,909,690 $ 13,256,000 3% $ 3,800 $ 3,800 $ 3,800 00/0 $ - $ - $ - 0 $ 1,500 $ 3,000 $ 3,200 7% $ $ $ - 0 $ 1,000 $ 1,100 $ 1,200 9% $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ $ 12,596,439 6,433,227 $ $ 13,457,690 8,035,588 $ $ 13,804,000 8,266,000 3 %p 3% $ 212,329 $ 223,165 $ 227,000 2% $ 1,291,376 $ 1,397,122 $ 1,483,000 6% $ 184,846 $ 211,165 $ 221,723 5 % $ 4,450,512 $ 3,551,158 $ 3,582,277 1% $ 12,572,290 $ 13,418,198 $ 13,780,000 3 %Q SURPLUS /(DEFICIT) FOR PERIOD: 1 $ 24,1491$- 39,492 1 $ 24,000 -39% FY 2015 -16 Comparative Agency Budget Revised 9/2912014 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Duke HomeCare & Hospice Program Primary Contact and Title: William Holloman, Hospice Bereavement & Family Services Telephone Number: 919.618.8954 E -Mail: VVilliam.holloman@duke.edu a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: Healthcare 1 Safety ❑ Priority Area #2 ❑ Priority Area #3: b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods /Residents Affordable Housing Affordable Healthcare Education x x X Family Resources Jobs /Jobs Training x x x Food Transportation Other: Please specify grief counseling x x x c) 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, briefly describe the coordinated /collaborative efforts. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town /County priority /goal? e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council /Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. DO NOT SUBMIT THIS PAGE 1/19/2018 3:41:03 PM Page 7 of DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION See attached for (f -m) f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) h) Describe the specific period over which the activities will be carried out and include an implementation timeline. i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. k) What percentage of your target population is low- moderate income? 1) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc. ?) m) Include any other pertinent information. DO NOT SUBMIT THIS PAGE 1/19/2018 3:36 :29 PM Page 8 of 11 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information n) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Gender Program Target Population demographics I Male Female Total Ethnicity African- American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify Total Of the above, how many Hispanic /Latino Of the above, how many non - Hispanic /Latino Total Age 0 -5 years 6 -18 years 19 -50 years 51 + years Total Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non - Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) Actual Estimated Projected 2016 -17 2017 -18 2018 -19 36 38 40 61 64 67 97 102 107 2 2 2 0 0 0 3 3 3 88 92 97 0 0 0 4 4 4 97 102 107 0 2 4 97 100 103 97 102 107 0 0 0 97 0 0 1 2 4 96 100 103 97 102 107 17 18 19 13 15 17 1,003 1,053 1,106 132 139 43 Total 1 97 102 1 107 DO NOT SUBMIT THIS PAGE 1119/2018 12:42:41 PM Page 9 of 11 38 40 42 2 2 2 39 41 43 6 6 7 12 13 13 Total 1 97 102 1 107 DO NOT SUBMIT THIS PAGE 1119/2018 12:42:41 PM Page 9 of 11 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement o) Complete the Work Statement Chart to describe the work to be performed. This chart 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. Every program is required to have A T LEAST 1 Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time- bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly /disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday - Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. 'Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program See Attached 1. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 2. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 3. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results DO NOT SUBMIT THIS PAGE 1/19/2018 112:42-41 PM Page 0 of 11 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION FY18 -19 Application Work Statement (Page 11) Goals: Duke Hospice Bereavement Services (DHBS) offers bereavement support to bath hospice and community clients 1) DHBS will schedule 200 community adult client encounters in FY18 2) DHBS will schedule 64 community child /teen encounters in FY18 3) DHBS will schedule 345 hospice adult client encounters in FY18 4) DHBS will schedule 26 hospice child /teen encounters in FY18 5) Camp ReLEAF will provide an overnight camp experience for children K -81' grade 6) DHBS will provide grief education and support to local educational and civic organizations as requested Goal # Actual 15 -16 Actual 16 -17 Estimated 17 -18 1 277 205 179 2 24 33 32 3 446 491 533 4 38 47 31 5 10 = .334 of total 16 = .381 of total 15 = .31 of total 6 17 18 16 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. 42 campers FY17 out of 48 FY17 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 98% satisfaction 100 refer services 4 95% satisfaction 98% refer services 6 94% satisfaction 100% refer Actual 96% 97% refer services 96% satisfaction 100% refer services 95% satisfaction 92% refer Estimated 95% 95% refer services 95% satisfaction 95% refer services 95% satisfaction 95% refer `services DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION p) Program Budget 1. Submit your program budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues c Private Donations © Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) o Other Government Grants • Triangle United Way • State Government • Federal Government (CDBGIHOME /etc.) • Private Foundation Grants o Other Revenue • Expenditures o Compensation c Rent & Utilities o Supplies & Equipment c Travel & Training o Other Expenses 2, Program Budget Detail Provide description of "other" budget items, not defined. Administrative Expenses $2,544,474 Nursing Home Room & Board $ 410,000 Employee Travel for Visiting Staff $ 202,198 3. This program budget represents what percent of the agency budget? 100% 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. DO NOT SUBMIT THIS PAGE 1/19/2018 3:37:52 PM P . -q - 1 1 0 f i 1 Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Total Cost of Program $12,572,290 $13,181,198 $13,780,000 Total # of Individuals $58,775 $60,538 $61,749 Cost Per Individual $213.91 $221.65 $223.16 DO NOT SUBMIT THIS PAGE 1/19/2018 3:37:52 PM P . -q - 1 1 0 f i 1 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: PROGRAM REVENUE Private Donations Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Granville County Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEIetc.) Private Foundation Grants Other Revenue Total Program Revenue PROGRAM EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Total Program Expenses Duke Hospice SURPLUSI(DEFICIT) FOR PERIOD: 1 $ 24,149 $ 39,492 1 $ 24,000 1 -39% Actual 2016 -17 Estimated 2017 -18 Projected 2018• 19 Percent Change $ 480,719 $ 540,100 $ 539,800 0% $ 12,109,420 $ 12,909,690 $ 13,256,000 3% $ 3,800 $ 3,800 $ 3,800 0% $ - $ - $ - 0 $ 1,500 $ 3,000 $ 3,200 7% $ - $ - $ - 0 $ 1,000 $ 1,100 $ 1,200 9% $ - $ - $ - 0 $ $ $ - 0 $ $ $ 0 $ $ $ 0 $ $ $ - a $ $ - $ 0 $ $ - $ 0 $ $ 12,596,439 6,433,227 $ $ 13,457,690 8,035,588 $ $ 13,804,000 8,266,000 3% 3% $ 212,329 $ 223,165 $ 227,000 2% $ 1,291,376 $ 1,397,122 $ 1,483,000 6% $ 184,846 $ 211,165 $ 221,723 5% $ 4,450,512 $ 3,551,158 $ 3,582,277 1% $ 12,572,290 $ 13,418,198 $ 13,780,000 3% SURPLUSI(DEFICIT) FOR PERIOD: 1 $ 24,149 $ 39,492 1 $ 24,000 1 -39% DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 EXHIBIT "B" Scope of Services -- FY 2018 -19 Outside Agency Performance Agreement Agency blame: Duke University Health Systems, Inc. d/b /a Duke HomeCare chi Hospice Program Name: Duke Hospice Children's Bereavement Funding Award: $1,115 Outline how the agency will spend Orange County's funding award, Expense Description Amount wq es $620 Camp ReLEAF Supplies and activities $440 Grief pro ram supplies including printing expense 1 classroom su lies $55 Evaluation 1 Self-Report measures 95 % - 23 children Enrollment in Camp ReLEAF 50% - 12 children Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2019. • Grief Education and Support to 24 Children.. o Resource, Collaboration and Consultation with Change County Schools when requested o Enhance current grief coping skills o Support Development of grief coping skills • Camp ReLEAF / overnight grief camp for 10 children o Enrollment in weekend intensive grief support designed for ages 6-14 o Grief activities designed to enhance skills in understanding individual grief response o Education and support to develop and enhance grief coping skills 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 Initial Grief Risk Asessment and Intervention 24 children Enrollment in grief support group/ family intervention 70 % - 17 children Evaluation 1 Self-Report measures 95 % - 23 children Enrollment in Camp ReLEAF 50% - 12 children Satisfaction 95 % - 23 children Recommendation of Services 95%-23 children UocuSigned by: �C,Vttl/l. .� r1 Director of Finance `0280118B0F104B6... Certified by:, i-_ ,+ez)fftTr -�_ Title: Date: t (Provider's Signature) DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 ATTACHMENT "A" Orange County Certifications — FY 2018 -19 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. DocuSigned by: Certified by: _ _ 0280198�OF104B6... (Provider's Signature) Director of Finance 8/14/2018 Title: Date: (Duke HomeCare & Hospice) Orange County Outside Agency Performance Agreement Page 9 of 9 Rev. 7118 DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 Page 1 of 1 ��. CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 07/31/2018 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 have ADDITIONAL INSURED provisions or 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 Willis of North Carolina, Inc. c/o 26 Century Blvd P.O. Box 305191 CONTACT NAME: PHONE 1- 877 - 945 -7378 FAX 1- 888 - 467 -2378 (.1C' No Ext : A/C No E -MAIL ADDRESS: certificates @willis.com INSURER(S) AFFORDING COVERAGE NAIC # Nashville, TN 372305191 USA INSURERA: Duke University Risk Management Trust Fund B1512 INSURED Duke University INSURER B : $ 2,000,000 CLAIMS -MADE � OCCUR Attn Chris Boroski INSURER C, INSURER D, PO Box 104143 Durham, NC 27708 INSURER E, INSURER F: $ A COVERAGES CERTIFICATE NUMBER: W7067509 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD/YYYY LIMITS Hillsborough, NC 27278 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE � OCCUR PREM SES� a oNcur ante $ 300,000 MED EXP (Any one person) $ A PERSONAL & ADV INJURY $ 1,000,000 GL- DURMRA 01/01/2018 01/01/2019 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑ JECT PRO- ❑ LOC PRODUCTS - COMP /OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OTH- STATUTE ER ANYPROPRIETOR /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 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) This Voids and Replaces Previously Issued Certificate Dated 12/29/2017 WITH ID: W4967982. Coverage includes sexual misconduct. CERTIFICATE HOLDER CANCELLATION ©1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 16517968 BATCH: 807349 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Orange County Government AUTHORIZED REPRESENTATIVE 200 South Cameron Street P.O. Box 8181 rr�� Hillsborough, NC 27278 L Ite - r- ©1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 16517968 BATCH: 807349