HomeMy WebLinkAboutR 2014-579 Health - UNC School of Dentistry ORANGE COUNTY-CONTRACT CONTROL SHEET
Routing Order : ( 1 ) Department, (2 ) IT , (3 ) Risk Management, (4 ) Financial Services , ( 5 ) Attorney, ( 6 ) Manager, (7 ) Clerk
This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above . If the Manager
determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval . Contracts for
BOCC approval must be submitted through , and complete , the routing process prior to agenda review . Contracts for legal review should
be completed through the legal review process prior to being routed for signature .
Department
Party/Vendor Name : Unc School of Dentistry Party/Vendor Contact Person : Martha B . Barbour Contact Phone : Party/Vendor
Address : 3150 Old Dental bldg City Chapel Hill State : NC Zip : 27599 Department : Public Health Amount : $ 56 , 848 Purpose : Provider
will provide one or more postgraduate year one or two level in the Dental Health Services Divsions to provide ambulatory dental services
for the academic year 2014 -2015 Budget Code (s ) : 10410420 - 630000 Vendor # 36302 (N/A if new vendor) Vendor is a BOCC
consultant? Yes ❑ No ® Contract Type : ( Check one) New ❑ Renewal ® Amendment ❑ Effective Date July 1 , 2014 Approved
by Board Yes ❑ No ❑ Agenda Date : July 1 , 2014 - June 30 , 2015 Title of Contract . Graduate Resident Services
If this is a Grant Agreement, pre - application has been approved by the Board of Commissioners Yes ❑ No ❑ . If submitted for bid were
bids/RFPs received Yes ❑ No ❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content :
Department Director ' s Signature : Date : [ '�40E kalve &10e,;4 J
y
Director
(Applicable on y e/so are purchases or related services) This contract has been reviewed and approved by the n ormation
Technology Director as to technical content an in hnology specifications :
J1 Neete�-' ig Date :
Risk Management
Include the following coverages : ❑ CGL ; ❑ Autos ❑ WC ; ❑ Professional ; ❑ Property ; OR No Insurance Required ❑ . Hold
Contract pending receipt of Certificate of Insurance ❑ . With incorporation of Insurance provisions as sho is contract is approved
by the Risk Manager :
Risk Manager ' s Signature : 4 �--- Date :
� DEC - 9 2014
Financial Services
This Contract is conditioned Vpon appropriation by the Board of Commissioners Yes ❑ Noll/ A bu pyamendment is necessary
before approval Yes ❑ No 1k.. If budget amendment is necessary, please attach to this form . This instrument has Wiff1j, pre - au i e
manner required by the Local Government Budget and Fiscal Control Act : Lf
Financial Services Director ' s Signature : q^A44% V%mof if Date :
County Attorney_
Approval by Board ❑ (Contracts $ 90 , 000 . 00 or more for goods or services , $ 250 , 000 . 00 or more for construction , or any BOCC
consultant contract) . Approval by an ger Most other contracts $ 1 , 000 and above) . Department Director approval only ❑ (Under
$ 1 , 000 ) . This contract has been re ew and pr ed by the Attorney as to legal form and sufficiency :
Attorney ' s Signature Date :
County Manager
This contract has been reviewed and is approved by the County Manager Yes No ❑ .
This contract has been reviewed and i r signa e b the Chair Yes ❑ No ❑ .
MOP
Managers Signature : Date :
Clerk to the Board
Approved by BOCC on the day of , 20.. Submitted for Chair signature on the day of , 20
Clerk ' s Signature : Date :
Revised March 2012