HomeMy WebLinkAboutR 2020-230 Health - Pamela Hines Business Associate Agreement DocuSign Envelope ID:COB 1 73FE-65A7-41 C5-985D-8D6B23DF80FB
ORANGE COUNTY—DEPARTMENT USE ONLY
Party/Vendor Name: Pamela Hines Party/Vendor Contact Person: Pamela Hines Contact Phone: (336) 410-3067
Party/Vendor Address: 160 Clayton Street City Roxboro State: NC Zip: 27573 Department: Health Amount: 1560
Purpose: Clinical Supervision for Clinical Social Worker Budget Code(s): 10414020-630000-71410 Vendor # N/A
(N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one)New ® Renewal
❑ Amendment ❑ Effective Date 4-6-20 Approved by Board Yes❑No❑ Agenda Date:
This agreement is approved as to technical form and content and I as Department Director affirmatively state work on
this project has not been initiated prior to execution of the agreement:
DocuSigned by:
Department Director's Signature- S�.w�- Date: 3/30/2020
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Agreements for emergency services or repair are not subject to the above affirmation. If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that was
addressed:
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 sufficient -Diocusigned by: 'ds, specifications,and requirements:
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Office of the Risk Management Officer 7FDCF9176800498... Date:
Financial Services
This instrument has been pre-audited it DocuSigned by: the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer ` q 4oas,acc,ao9...� Date: 3/30/2020
Legal Services
This agreement is approved as tc DocuSigned by:
"k �Yf, U(h 3/30/2020
Office of the County Attorney Date:
079A40525COF4FB...
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Sherri Ingersoll upon completion: singersoll@orangecountync.gov
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 12/18 4