HomeMy WebLinkAboutR 2017-704-E Health - CHCCS FPG business associate agreement DocuSign Envelope ID:8332B88E-6069-4FC9-98F9-6D884A2A8399
ORANGE COUNTY—DEPARTMENT USE ONLY
Department
Party/Vendor Name: Chapel Hill Carrboro County Schools Party/Vendor Contact Person: Dr. Rydelll Harrison
Contact Phone: 919-967-8211 Party/Vendor Address: 750 S. Merritt Mill Road City Chapel Hill State: NC Zip:
27516 Department: Health Amount: $2,500 Purpose: After school literacy tutoring program. Budget Code(s):
10412020-630000-71453 Vendor#22226 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No®
Contract Type: (Check one)New ❑ Renewal ® Amendment ❑ Effective Date 11-1-17 Approved by Board
Yes❑No[] Agenda Date:
This agreement is approved as to tei DOCUSigned by: nt:
pbrb&� �,lwC,l 1 11/14/2017
Department Director's Signature Date:
5145A2C6945C4flF...
Information Technologies
(Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer Date:
Risk Management
This agreement is approved for sufficienc, -QocuSigned by: ds, specifications,and requirements:
QUsa. LA�b 11/15/2017
Office of the Risk Management Officer 7FDCF9176800498... Date:
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control
Act: DocuSigned by;
41.&1. 11/20/2017
Office of the Chief Financial Officer 7DaE51a1ACC140s... Date:
Legal Services
This agreement is approved as t OacuSigned by:
1WAZ ftaYit, 11/20/2017
Office of the County Attorney 079MD525COF4FB... Date:
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd&oran eg countync. og_v
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board Date:
Revised 10/17
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