HomeMy WebLinkAbout2019-347-E Health - Melynee Falk audiology servicesRevised 12/18
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[Departmental Use Only]
TITLE Falk, Melynee EDHI
FY 2019-2020
NORTH CAROLINA
SERVICES AGREEMENT UNDER $90,000.00
NO RFP/RFQ
ORANGE COUNTY
This Services Agreement (hereinafter “Agreement”), made and entered into this 7th day of
June, 2019, (“Effective Date”) by and between Orange County, North Carolina a political
subdivision of the State of North Carolina (hereinafter, the "County") and Melynee Falk,
(hereinafter, the "Provider").
WITNESSETH:
That the County and Provider, for the consideration herein named, do hereby agree as
follows:
1. Services
a. Scope of Work.
i) This Agreement is for services to be rendered by Provider to County with respect
to (insert type of project): Audiology consulting services.
ii) By executing this Agreement, the Provider represents and agrees that Provider is
qualified to perform and fully capable of performing and providing the services
required or necessary under this Agreement in a fully competent, professional and
timely manner.
iii) Time is of the essence with respect to this Agreement.
iv) The services to be performed under this Agreement consist of Basic Services, as
described and designated in Section 3 hereof. Compensation to the Provider for
Basic Services under this Agreement shall be as set forth herein.
2. Responsibilities of the Provider
a. Services to be provided. The Provider shall provide the County with all services
required in Section 3 to satisfactorily complete the Project within the time limitations set
forth herein and in accordance with the highest professional standards.
b. Standard of Care.
i) The Provider shall exercise reasonable care and diligence in performing services
under this Agreement in accordance with the highest generally accepted standards
of this type of Provider practice throughout the United States and in accordance
with applicable federal, state and local laws and regulations applicable to the
performance of these services. Provider is solely responsible for the professional
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quality, accuracy and timely completion and/or submission of all work related to
the Basic Services.
ii) Provider shall be responsible for all errors or omissions of its agents, contractors,
employees, or assigns in the performance of the Agreement. Provider shall
correct any and all errors, omissions, discrepancies, ambiguities, mistakes or
conflicts at no additional cost to the County.
iii) The Provider shall not, except as otherwise provided for in this Agreement,
subcontract the performance of any work under this Agreement without prior
written permission of the County. No permission for subcontracting shall create,
between the County and the subcontractor, any contract or any other relationship.
iv) Provider is an independent contractor of County. Any and all employees of the
Provider engaged by the Provider in the performance of any work or services
required of the Provider under this Agreement, shall be considered employees or
agents of the Provider only and not of the County, and any and all claims that may
or might arise under any workers compensation or other law or contract on behalf
of said employees while so engaged shall be the sole obligation and responsibility
of the Provider.
v) If activities related to the performance of this Agreement require specific licenses,
certifications, or related credentials Provider represents that it and/or its
employees, agents and subcontractors engaged in such activities possess such
licenses, certifications, or credentials and that such licenses certifications, or
credentials are current, active, and not in a state of suspension or revocation.
vi) In determining the basic services to be provided, should any documents be
referenced in this Agreement, the terms of this Agreement shall have priority in
any conflict between the terms of referenced documents and the terms of this
Agreement. Should a request for proposals and a proposal be referenced the
terms of the request for proposals shall have priority over the terms of any
proposal.
3. Basic Services
a. Basic Services. The Services to be rendered pursuant to this Agreement are as follows
(fully describe services to be provided): Provide regional audiology consulting services
for the NC Early Hearing Detection and Intervention (EHDI) program to hospitals and
other public and private agencies. Follow the work plan developed by State EHDI
Program staff as stated in subsection B under section III of the Division of Public Health
Agreement Addendum FY 19-20: 324 Speech and Hearing attached as Exhibit A and
any amendments thereto, both of which are attached and hereby incorporated by
reference. Attend all DPH, C&Y Branch EHDI program training events and staff
meetings. Attend conferences and workshops as directed by the DPH C&Y Branch
EHDI program and supported by Agreement Addendum funds. Perform duties in
subsection A under section IV of Exhibit A.
4. Duration of Services
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a. Term. The term of this Agreement shall be from June 1, 2019 to May 31, 2020.
b. Scheduling of Services.
i) The Provider shall schedule and perform its activities in a timely manner.
ii) Should the County determine that the Provider is behind schedule, it may require
the Provider to expedite and accelerate its efforts, including providing additional
resources and working overtime, as necessary, to perform its services in
accordance with the approved project schedule at no additional cost to the
County.
iii) The Commencement Date for the Provider's Basic Services shall be June 1, 2019.
5. Compensation
a. Compensation for Basic Services. Compensation for Basic Services shall include all
compensation due the Provider from the County for all services under this Agreement.
The maximum amount payable for Basic Services shall not exceed Seventy Seven
Thousand Five Hundred Ninety Seven Dollars ($77,597). Payment for Basic Services
shall become due and payable within thirty (30) days of Provider properly invoicing
County. Payment shall be subject to provisions of Section 5(b).
b. Disputes. In the event the amount stated on an invoice is disputed by the County, the
County may withhold payment of all or a portion of the amount stated on an invoice
until the parties resolve the dispute. Should Provider fail to perform its duties under the
terms of this Agreement, County may, without fault or penalty, withhold any payment
associated with the work to be performed until such time as said work is completed.
c. Additional Services. County shall not be responsible for costs related to any services in
addition to the Basic Services performed by Provider unless County requests such
additional services in writing and such additional services are evidenced by a written
amendment to this Agreement.
6. Responsibilities of the County
a. Cooperation and Coordination. The County has designated (Rebecca Crawford) to act as
the County's representative with respect to the Project and shall have the authority to
render decisions within guidelines established by the County Manager and/or the County
Board of Commissioners and shall be available during working hours as often as may be
reasonably required to render decisions and to furnish information.
7. Insurance
a. General Requirements. Provider shall obtain, at its sole expense, Commercial General
Liability Insurance, Automobile Insurance, Workers’ Compensation Insurance, and any
additional insurance as may be required by County’s Risk Manager as such insurance
requirements are described in the Orange County Risk Transfer Policy and Orange
County Minimum Insurance Coverage Requirements (each document is incorporated
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herein by reference and may be viewed at
http://www.orangecountync.gov/departments/purchasing_division/contracts.php). If
County’s Risk Manager determines additional insurance coverage is required such
additional insurance shall consist of N/A (if no additional insurance required mark N/A
as being not applicable). Provider shall not commence work until such insurance is in
effect and certification thereof has been received by the County's Risk Manager.
8. Indemnity
a. Indemnity. The Provider agrees, without limitation, to defend, indemnify and hold
harmless the County from all loss, liability, claims or expense, including attorney's fees,
arising out of or related to the Project and arising from property damage or bodily injury
including death to any person or persons caused in whole or in part by the negligence or
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 provision to require the Provider
to indemnify the County to the fullest extent permitted under North Carolina law.
9. Amendments to the Agreement
a. Changes in Basic Services. Changes in the Basic Services and entitlement to additional
compensation or a change in duration of this Agreement shall be made by a written
Amendment to this Agreement executed by the County and the Provider. The Provider
shall proceed to perform the Services required by the Amendment only after receiving a
fully executed Amendment from the County.
10. Termination
a. Termination for Convenience of the County. This Agreement may be terminated without
cause by the County and for its convenience upon seven (7) days’ prior written notice to
the Provider.
b. Other Termination. The Provider may terminate this Agreement based upon the County's
material breach of this Agreement; provided, the County has not taken all reasonable
actions to remedy the breach. The Provider shall give the County seven (7) days' prior
written notice of its intent to terminate this Agreement for cause.
c. Compensation After Termination.
i) In the event of termination, the Provider shall be paid that portion of the fees and
expenses that it has earned to the date of termination, less any costs or expenses
incurred or anticipated to be incurred by the County due to errors or omissions of
the Provider.
ii) Should this Agreement be terminated, the Provider shall deliver to the County
within seven (7) days, at no additional cost, all deliverables including any
electronic data or files relating to the Project.
d. Waiver. The payment of any sums by the County under this Agreement or the failure of
the County to require compliance by the Provider with any provisions of this Agreement
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or the waiver by the County of any breach of this Agreement shall not constitute a
waiver of any claim for damages by the County for any breach of this Agreement or a
waiver of any other required compliance with this Agreement.
e. Suspension. County may suspend the Basic Services and this Agreement at any time for
County’s convenience and without penalty to County upon three (3) days’ notice to
Provider. Upon any suspension by County, Provider shall discontinue work on the Basic
Services and shall not resume the Basic Services until notified to proceed by County.
11. Additional Provisions
a. Limitation and Assignment. The County and the Provider each bind themselves, their
successors, assigns and legal representatives to the terms of this Agreement. Neither the
County nor the Provider shall assign or transfer its interest in this Agreement without the
written consent of the other.
b. 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 identified, on the list created by the State Treasurer pursuant to
G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not
been identified, and has not utilized the services of any agent or subcontractor identified,
on the list created by the State Treasurer pursuant to G.S. 147-86.81.
c. Non-Discrimination. Provider shall at all times remain in compliance with all applicable
local, state, and federal laws, rules, and regulations including but not limited to all state
and federal non-discrimination laws, policies, rules, and regulations and the Orange
County Non-Discrimination Policy and Orange County Living Wage Policy (each policy
is incorporated herein by reference and may be viewed at
http://www.orangecountync.gov/departments/purchasing_division/contracts.php.) Any
violation of the Orange County Non-Discrimination Policy is a breach of this Agreement
and County may immediately terminate this Agreement without further obligation on the
part of the County. This paragraph is not intended to limit and does not limit the
definition of breach to discrimination.
d. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages
with respect to any provision of, or the performance or non-performance of, this
Agreement shall be brought in the General Court of Justice of North Carolina sitting in
Orange County, North Carolina. It is agreed by the parties that no other court shall have
jurisdiction or venue with respect to such suits or actions. Binding arbitration may not
be initiated by either Party, however, the Parties may agree to nonbinding mediation of
any dispute prior to the bringing of such suit or action.
e. Entire Agreement. This Agreement represents the entire and integrated agreement
between the County and the Provider and supersedes all prior negotiations,
representations or agreements, either written or oral. This Agreement may be amended
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only by written instrument signed by both parties. Modifications may be evidenced by
facsimile signatures.
f. Severability. If any provision of this Agreement is held as a matter of law to be
unenforceable, the remainder of this Agreement shall be valid and binding upon the
Parties.
g. Ownership of Work Product. Should Provider’s performance of this Agreement generate
documents, items or things that are specific to this Project such documents, items or
things shall become the property of the County and may be used on any other project
without additional compensation to the Provider. The use of the documents, items or
things by the County or by any person or entity for any purpose other than the Project as
set forth in this Agreement shall be at the full risk of the County.
h. Non-Appropriation. Provider acknowledges that County is a governmental entity, and
the validity of this Agreement is based upon the availability of public funding under the
authority of its statutory mandate.
In the event that public funds are unavailable and not appropriated for the performance of
County’s obligations under this Agreement, then this Agreement shall automatically
expire without penalty to County immediately upon written notice to Provider of the
unavailability and non-appropriation of public funds. It is expressly agreed that County
shall not activate this non-appropriation provision for its convenience or to circumvent
the requirements of this Agreement, but only as an emergency fiscal measure during a
substantial fiscal crisis.
In the event of a change in the County’s statutory authority, mandate and/or mandated
functions, by state and/or federal legislative or regulatory action, which adversely affects
County’s authority to continue its obligations under this Agreement, then this Agreement
shall automatically terminate without penalty to County upon written notice to Provider
of such limitation or change in County’s legal authority.
i. Signatures. This Agreement together with any amendments or modifications may be
executed electronically. All electronic signatures affixed hereto evidence the consent of
the Parties to utilize electronic signatures and the intent of the Parties to comply with
Article 11A and Article 40 of North Carolina General Statute Chapter 66.
j. Notices. Any notice required by this Agreement shall be in writing and delivered by
certified or registered mail, return receipt requested to the following:
Orange County Provider’s Name
Attention: Kimberlee Quatrone Melynee Falk
P.O. Box 8181 1406 Valleymede Rd.
Hillsborough, NC 27278 Greensboro, NC 27410
[SIGNATURE PAGE TO FOLLOW]
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IN WITNESS WHEREOF, the Parties, by and through their authorized agents, have
hereunder set their hands and seal, all as of the day and year first above written.
ORANGE COUNTY: PROVIDER:
By: _________________________________
County Manager
By: __________________________________
Melynee M. Falk, M.A., CCC-A
Printed Name and Title
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Exhibit A
Division of Public Health
Agreement Addendum
FY 19-20
Page 1 of 5
Women's and Children's Health i
Orange County Health Department Children and Youth
Local Health Department Legal Name DPH Section/Branch Name
Marcia Fort, 919-707-5630,
324 Speech and Hearing Marcia.Fort@dhhs.ne.gov _
Activity Number and Description DPH Program Contact
(name,phone number,and email)
06/01/2019—05/31/2020
Service Period DPH Program Signature Date
(only required for a negotiable agreement addendum)
07/01/2019-06/30/2020
Payment Period
® Original Agreement Addendum
❑ Agreement Addendum Revision #
I. Background:
Hearing loss is the most common congenital birth defect, affecting as many as three infants per thousand
born. Left undetected, hearing loss in infants can negatively impact speech and language acquisition.,
academic achievement, and social and emotional development. If detected, however, these negative
impacts can be diminished and even eliminated through early intervention. Infants who fail the initial
newborn hearing screening are at a higher risk than the general population of having a hearing loss. The
most recent data from the Centers for Disease Control (CDC), for infants born in 2016, shows that
25.4% of infants in the United States and 34.4%in the state of North Carolina with a failed newborn
hearing screen are subsequently"lost to follow up."
The primary goal of the Children and Youth Branch's North Carolina Early Hearing Detection and
Intervention (EHDI) Program is to ensure that all infants are screened for hearing loss by one month of
age; that children with congenital hearing loss are identified by three months of age; and that all are
provided access to appropriate audiological, educational, and medical intervention by six months of age.
Regional staffing is needed to support hospital universal newborn hearing screening programs in order
to: 1)ensure that infants receive additional hearing screening when needed, 2) support families through
the diagnostic and/or intervention processes, if necessary,and 3) provide consultation,technical
assistance and resources to public and private agencies for the development and implementation of
effective Early Hearing Detection and Intervention programs. Regional staffing is also needed to
provide support and assistance to parents and families whose children have hearing loss and to provide
assistance to other professionals working with these families.
ljalz�u1�,j 3 - 24
Heafi Director Signature (use blue ink) Date
Local Health Department to complete: LHD program contact name: (,Ctk. r
(If follow-up information is needed by DPH) Phone number with area code: • 24 - 7�1 i�
Email address: C r, 12'r•, cQC C V
Signature on this page signifies you have read and accepted all pages of this document. Revised July2018
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H. Purpose'
This Agreement Addendum provides support for maintaining and improving the EHDI program by
identifying and designating no more than 0.75 FTE Audiologist to act as a Child Health Audiology
Consultant(CHAC} in the north central part of North Carolina. This CHAC shall act as part of the DPH
EHDI Team,with oversight of his or her EHDI program responsibilities carried out by State EHDI
Program staff.
III. Scope of Work and Deliverables:
A. The Local Health Department shall:
1. Provide one three-quarter-time (0.75 FTE) audiologist to perform as the Child Health Audiology
Consultant(CHAC}on the Division of Public Health(DPH) EHDI team.
2. Collaborate with the DPH Genetics and Newborn Screening Unit Manager to ensure that all
responsibilities of the CHAC work plan, as described in Paragraph B below,meets the standards
set by the Local Health Department and the EHDI program. The CHAC will be expected to
meet the program requirements as determined by the DPH EHDI Program,
3. Ensure that the CHAC provides direct and indirect services to identify and assist children with
hearing loss in the following counties: Forsyth, Guilford, and Orange. For these counties,the
estimated number of births for the state fiscal year 2019-2020 is 12,388. An estimated 24 to 36
(2 to 3 per 1,000 births) of these infants will have some form of hearing loss, and an additional
459 infants will need follow-up from newborn hearing screening to determine their hearing
status.
4. Assure that this CHAC has a master's degree in Audiology and that the CHAC maintains current
certification and licensure from the American Speech-Language-Hearing Association and the
North Carolina Board of Speech Language Pathologists and Audiologists.
5. Within five working days, notify the EHDI program of any staff changes as a result of
employment termination of the person designated as the CHAC.
6. Agree not to bill families or third parties for services provided under this Agreement Addendum.
7. Ensure that the CHSLC attends:
a. All DPH EHDI Program training events and staff meetings as requested.
b. Conferences and workshops as directed by the program and supported by Agreement
Addendum funds.
c. The National Early Hearing Detection and Intervention Meeting in March 2019 in Rosemont,
Illinois.
8. Ensure that the CHAC submits the reports and monthly service logs as required by the EHDI
program.
9. Provide adequate workspace for the CHAC.
10. Serve as the purchasing agent for newborn hearing screening disposable testing supplies used
within the catchment area for this Agreement Addendum.
11. Serve as purchasing agent for maintenance,replacement or purchase of equipment used for
hearing screening and rescreening to the extent possible with the funds provided with this
Agreement Addendum.
B. The Local Health Department's Child Health Audiology Consultant (CHAC} shall follow the work
plan developed by the DPH Genetics and Newborn Screening Unit Manager which will include,but
is not limited to, the following activities:
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1. Provide technical assistance to birthing facilities for hearing screening, rescreening and tracking
of infants born at each facility.
2. Provide consultation and technical assistance to public and private agencies (other stakeholders)
focusing on identification and intervention for children with hearing loss or communication.
delays.
3. Provide technical assistance regarding the WCSWeb Hearing Link,North Carolina's direct data
entry and tracking system.
4. Coordinate regional educational and networking meetings about newborn hearing screening for
personnel from birthing facilities and other involved stakeholders.
5. Keep track of data concerning the efficiency and effectiveness of each birthing facility in the
region and intervene when a facility appears to be missing hearing screenings on children or has
an excessive number of children who fail the screening.
5. Identify community resources and systems that identify and refer infants and children with
suspected late onset or progressive hearing loss or communication deficits.
7. Collaborate with care managers, private providers, local health departments, and others for the
tracking of infants and children with or at risk for hearing loss.
8. Supply educational materials about hearing loss and communication delays to agencies working
with families of young children.
9. Collaborate with community resources to screen children as part of special health promotion
events or part of Head Start or other community mass screening initiatives.
10. Provide support to individual families whose children have not had a newborn hearing screening
or have failed a hearing screening to ensure that they obtain the needed repeat hearing screenings
or diagnostic evaluations to determine the absence or presence of hearing loss.
11. Provide support to individual families whose children have been diagnosed with hearing loss to
ensure that they obtain the needed intervention services and family support services.
12. Promote public awareness related to the benefits of early hearing detection and intervention.
13.Identify and develop resources for provision of services to families in a culturally appropriate
setting and in their own language.
14. Educate private providers regarding the benefits of early hearing detection and intervention and
the reporting requirements of the State.
15. Coordinate with professionals in the DPH, Children and Youth Branch's Early Intervention
Program regarding service delivery and transition issues for children with hearing loss.
16. Collaborate with other regional consultants to identify and develop appropriate communication-
related practices, skills and techniques,
17. Consult with public and private agencies and families in the selection and procurement of
communication-related equipment and/or other assistive devices/technology.
18. Collaborate with local audiologists in the expansion and development of audiology services for
children birth to 21 years.
19. Collaborate with academia to provide training opportunities for students.
20. Screen each child served directly for health insurance status and refers and assists each child's
parents or guardians to obtain needed health insurance coverage.
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IV. Performance Measures/Reporting Requirements:
A. Electronic submission of service logs is required monthly of the CHAC and are clue to State EHDI
Program staff by the fifth day of the following month. The monthly services logs shall include:
1. Performance Measure#1: Evidence of at least 25 consultations, technical assistance, and/or
training sessions per month provided for hospitals and other EHDI stakeholders.
2. Performance Measure#2: Evidence of timely interventions with 95%of families whose children
need follow-up from a newborn hearing screening. Entries will be made in the WCSWeb
Hearing Link notes section to document counseling and education provided to families of
children who failed the newborn hearing screening, and to document consultation with their
direct service providers.
3. Performance Measure#3: Evidence of timely coordination of service delivery for children with
or at risk of hearing loss. This will include:
a. At least four in-service sessions provided to community collaborators or private providers
per year;
b. At least three public awareness activities per year; and
c. The total number of hearing screenings provided at mass screening events.
V. Performance Monitoring and Quality Assurance:
A. The Local Health Department shall adhere to the following Quality Assurance measures:
1. Ensure that the CHAC is board certified.
2. Ensure that the CHAC is licensed in North Carolina.
3. Ensure that services are provided in a culturally and linguistically appropriate manner.
B. The state EHDI Program staff will monitor the CHAC's work plan progress through:
1. Monthly reviews of electronic service logs.
2. Quarterly contacts(phone and email)with the CHAC.
3. An annual site visit with the Local Health Department, and with additional visits if needed.
4. Semi-annual review of CHAC's work.
5. Quarterly reviews of data from the WCSWeb Hearing Link data tracking system on hospitals
served by the CHAC.
6, Meetings with the CHAC during DPH EHDI Team Meetings and other DPH required activities.
C. Should the performance of the CHAC be deemed inadequate because of non-completion of expected
activities,poor communication with team members or community collaborators, or insufficient
documentation, a meeting will be convened with the Local Health Department supervisor to
determine an action plan or corrective measures.
VI. Funning Guidelines or,Restrictions:
A. Requirements for pass-through entities: In compliance with 2 CFR§200.331 —Requirements for
pass-through entities,the Division provides Federal Award Reporting Supplements to the Local
Health Department receiving federally funded Agreement Addenda.
1, Definition: A Supplement discloses the required elements of a single federal award. Supplements
address elements of federal funding sources only; state funding elements will not be included in
the Supplement. Agreement Addenda(AAs)funded by more than one federal award will receive
a disclosure Supplement for each federal award.
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2. Frequency: Supplements will be generated as the Division receives information for federal
grants. Supplements will be issued to the Local Health Department throughout the state fiscal
year. For federally funded AAs, Supplements will accompany the original AA, If AAs are
revised and if the revision affects federal funds, the AA Revisions will include Supplements.
Supplements can also be sent to the Local Health Department even if no change is needed to the
AA. In those instances, the Supplements will be sent to provide newly received federal grant
information for funds already allocated in the existing AA.
Revised July 201E
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- �.._.....p...11—� .....nw 1w v vj]-1111 UU611 1-1r2t:FIU 5,4 CFR§200.331
FYZO Activity: 324 CSHS Speech&Hearing Supplement 1
Supplement reason. ®in AA+BE or AA+BE Rev —OR— ❑ —
CFDA#: 93.778 Federal awd date: NGA date I Is award R&D? no FAIN: Unknown Total amount of fed awd: $ Unknown
Fed award
project Medicaid Administration Payments
CFDA Medical Assistance Progam(Medicaid:Title Hi%) description:
name.
Fed awarding DHHS,Health Resources and Services Federal award n/a %
agency: Administration Indirect cost rate:
5ubrecipient 5ubrecipient Fed funds for Total of All Fed Funds 5ubrecipient 5ubrecipient Fed funds for Total of All Fed Funds
DUNS This Supplement for This Activity DUNS This Supplement far This Activity
Ala mance 965194483 = = Jackson 019728518 = _
Albemarle 130537822 18623 18623 Johnston 097599104
Alexander D30495105 - = Jones 095116935 = -
Anson 847163029 = = Lee 067439703
Appalachian 780131541 - = Lenoir 042799748
Beaufort 091567776 = = Lincoln 086869336 = _
Bladen 084171628 = = Macon 070626825 =
Brunswick 091571349 = = Madison 831052873 =
Buncombe 879203560 = = MTW 087204173 = -
Burke 883321205 = = Mecklenburg 074498353 = _
Cabarrus 143408289 - = Montgomery 025384603
Caldwell 948113402 = - Moore 050988146 = _
Carteret 058735904 = = Nash 050425677 =
Caswell 077846053 - = New Hanover 040029563 = -
Catawba 083677138 - = Northampton 097594477 =
Chatham 131356607 - - Onslow 172663270
Cherokee 130705072 - - Orange 139209659 18623 18623
Clay 145058231 = = Pamlico 0976DO456 = _
Cleveland 879924850 = = Pender 100955413 = _
Columbus 040040016 = = Person 091563718
Craven 091564294 = = Pitt 080889694 = _
Cumberland 123914376 = = Randolph 027873132
Dare 082358631 = = Richmond 070621339
Davidson 077839744 = = Robeson 082367871 = »
Davie 076526651 = = Rockingham 077847143
Duplin 095124798 = = Rowan 074494014 =
Durham 089564075 = = RPM 782359004
Edgecombe 093125375 - - Sampson 825573975 = -
Forsyth 105316439 = Scotland 091564146 = _
Franklln 084168632 = = 5tanly 131060829 = _
Gaston 071062196 = = Stokes 085442705 = _
Graham 020952383 - - Surry 077821859 = =
Granville-Vance 063347626 - = Swain 146437553 -
Greene 091564591 = = Toe River 113345201 = _
Guilford 071563613 - - Transylvania 030494215 =
Hailfax 014305957 - - Union 079051637 -
Harnett 091565986 = = Wake 019625961 = _
Haywood 070620232 - _ Warren 030239953
Henderson 085021470 = - Wayne 040036170 -
Hoke 091563643 = = Wilkes 067439950 -
Hyde 832526243 = - Wilson 075585695 =
Iredell 074504507 = - Yadkin 089910624 = _
DocuSign Envelope ID:35E8DCE7-1CAA-4177-A55F-37F14DE3307B
WicGridPrint https:llatc.dhhs.state.nc,us/WICGridPrini.agpx
i]pH-Aid-To-Counties For Fiscal Year:19120 Budgetary Estimate Number e
_......_.. .................
Activity 324 AA 1332 Proposed New
6390 Total Total
99
Service Period 06101-05131
i
i Payment Period 07101.06130
101 Alamance 0 0 0'
f[Albemarle 0 77,597 77,597 77,597
Alexander 0 0 0
1Anson 0 0 0
Appalachfan 0 0 0.
107 Beaufort 0 0 0
If 09 Bladen 0 0 0
10 Brunswick 0 0 0
11 Buncombe 01 0 0.
12 Burke 0 0 0
13 Cabarrus 0 0 0
14 Caldwell 0 0 0'
16 Carteret 0 01 0'
17 Caswell 0 0 0
18 Catawba 1 0 0 0
19 Chatham 0 0 0:
20 Cherokee 0 0 0.
E 22 Clay 0 0 0
23 Cleveland 0 0 0
24 Columbus 0 0 0;
126 Craven 0 0 0,
i 26 Cumberland 0 0 0
128 Dare 0 0 0
129 ❑avldson 0 01 0
130 Davie 0 0 0
31 Duplin 0 0 0
132 Durham 0 0 0.
33 Edgecombe 0 0 0.
134 Forsyth 0 0 0
35 Franklin 0 0 0
136 Gaston 0 01 0
138 Graham 0 0 0
D3 Gran-Vance 1 0 0 0
140 Greene 0 0 0
"41 Guilford 0 0 0
42 Halifax 0 0 0.
43 Harnett Q 0 0!
144 Haywood 0 0 01
145 Henderson 0 0 0
46 Hertford 0 0 0
47 Hoke 0 0 0
48 Hyde 0 0 0
1 of 2 9/26/2018,2:19 PM
DocuSign Envelope ID:35E8DCE7-1CAA-4177-A55F-37F14DE3307B
WicGridPript fittps:llatc.clhhs.st'-t€c.nc.us/WIC'GricIPriiit,aspx
491redeil C 0 p'
150 Jackson 0 C 0'
151 Johnston 0 C 0'
52 Jones 0 C 01
I:53 Lee 0 0 0'
54 Lenoir 0 0 0
55 Lincoln 0 0 0
56 Macon 0 0 0.
57 Madison 0 0 0
04 M-T W 0 0 0
60 Mecklenburg 0 �io 0€
62 Montgomery 0 0 0;
163 Moore 01 0 0�
64 Nash 0 0 0
-,...............W
65 New Hanover 0 0 0,
66 Northampton 0 0 0.
67 Onslow 0 0 0.
68 Orange 0 77,597 77,597 77,597E
169 Pamlico 0
71 Pender 0 0 0I
73 Person 0 0 01
74 Pitt 0 0
76 Randolph 0 01 0.
77 Richmond 0 0 0
78 Robeson 0 _ 0
79 Rockingham _ 0 0 0
80 Rowan 0 0 0
❑5 R-P-M 0 (3 0
82 Sampson 0 0 0
83 Scotland 0 0 0
84 Stanly 0 0 0
85 Stokes 0 0 0
86 Surry 0 0 01
87 Swain 0 0 0
D6 Toe River 0 0 0
88 Transylvania 0 0 0
90 Anion 0 0
92 Wake 0 0 0
93 Warren 0 0 0..
96 Wayne 0 0 0
97 Wilkes fl 0 0
98 Wilson 0 0 0'
99 Yadkin 0 0 0'
Totals I55,194 155,194155,194
Sign and Date.OPH Program Administrator Sign an ate-DraH Section W,11je
Sfgn and pate-❑PH Cordracts dffice M
Date ❑P 6udg UHfcar J � r
-A
2 of 3l2612018,2:19 PM
DocuSign Envelope ID:35E8DCE7-1CAA-4177-A55F-37F14DE3307B
CI i ent #2271544
MEMORANDUM OF INSURANCE ate Issued 06/07/2019
Producer This memorandum is issued as a matter of information
only and confers no rights upon the holder. This
Mercer Consumer, a service of memorandum does not amend, extend or alter
Mercer Health& Benefi ts Admi ni strati on L L C coverages afforded by the Certificate listed below.
P.O. Box 14576
Des M of nes, I A 50306-3576
1-800-503-9230 Company Affording Coverage
Insured Liberty I nsurance U nderwr i ters I nc.
Mel ynee M Fal k
1406 V al I eymede Road
Greensboro, N C 27410
This is to certify that the Certificate listed below has been issued to the insured named above for the policy period indicated, not
withstanding any requirement, term or condition of any contract or other document with respect to which this memorandum may be
issued or may pertain,the insurance afforded by the Certificate described herein is subject to all the terms, exclusions and conditions of
such Certificate.The limits shown may have been reduced by paid claims.
The Memorandum of Insurance and verification of payment are your evidence of coverage.No coverage is afforded unless the premium
is successfully paid in full.
Type of Insurance Certificate Number Effective Date Expiration Date Limits
rofessionalLiability AHY-860875003 04/01/2019 04/01/2020 Per Incident/ $1,000,000
SpeechLangH SE Occurrence
Speech Language Pathologi
Annual Aggregate $3,000,000
ROOF OF INSURANCE
Memorandum Holder: Should the above describe Certificate be cancelled
before the expiration date thereof; the issuing company
PROOF OF COVERAGE ONLY ill endeavor to mail 30 days written notice to the
emorandum Holder named to the left but failure to
Roll SUCH 11UL1Ce SIMI 1111pUSe 110 0011gaL1011 Of 11ab111Ly
of any kind upon the compaw its Qge11LJ or
representatives.
Authorized Representative
Mark Brostowitz
G�VIc�-QL�Q..
Mercer Consumer, aserviceof Mercer Health& Benefits Administration LLC. In CA d/b/a Mercer Health& Benefits Insurance Services LLC. CA License#OG39709
DocuSign Envelope ID:35E8DCE7-1CAA-4177-A55F-37F14DE3307B
NC FARM BUREAU MUTUAL INS. CO. PROOF OF INSURANCE
0 P.O. Box 27427, Raleigh, NC, 27611-7427
NOTHING IN THIS DOCUMENT SHOULD BE CONSTRUED AS A WAIVER OF ANY POLICY TERMS OR
CONDITIONS. THIS DOCUMENT 1S INVALID IF POLICY 1S CANCELLED, TERMINATED OR EXPIRED.
Policy Number: APM 8445513 Effective Date: 02/21/19 Expiration Date:08/21/19 ti ,
Insured Vehicle: Year: 2015 Make: LEXS RX 350 AWD VIN: 2T2BK1 BA2FC270209
Agent's Name: JOHN G EDWARDS, LUTCF Phone Number: (336) 623-1025
Named Insured:
MELYNEE FALK
1406 VALEEYMEDE RD IMPORTANT: PLEASE PLACE IN DESIGNATED VEHICLE
GREENSBORO, NC 27410-3938
NAIL Number: 14842 01/12/19
Authoriz presentative Date
XXXXXXXXXXXXXXXXXXXXXXXXXXX PROOF OF INSURANCE
G P.O. Box 27427, Raleigh, NC; 2761 1-7427
NOTHING IN THIS DOCUMENT SHOULD BE CONSTRUED AS A WAIVER OF ANY POLICY TERMS OR
CONDITIONS. THIS DOCUMENT IS INVALID IF POLICY IS CANCELLED, TERMINATED OR EXPIRED.
Policy Number: XXX XXXXXXX Effective Date: XXXXXXXX Expiration Date: XXXXXXXX
Insured Vehicle: Year: XXXX Make: XXXXXXXXXXXXXXXXX VIN: XXXXXXXXXXXXXXXXX
Agent's Name: XXXXXXXXXXXXXXXXXXXXXX Phone Number: XXXXXXXXXXXXX
Named Insured:
MELYNEE FALK
1CAa6 VALLEYMEDE R❑ IMPORTANT: PLEASE PLACE IN DESIGNATED VEHICLE
GREENSBORO, NC 27410-3938
C N : X XXXXXXXX
N AI umber XXXX
Authoriz presenta4ve Date