HomeMy WebLinkAbout2020-361-E Health-NC DHHS consolidated services agreement FY20-21Consolidated Agreement FY21 Page 1 of27
FY 2021 CONSOLIDATED AGREEMENT
This Agreement is made between the North Carolina Department of Health and Human Services, Division
of Public Health (hereinafter referred to as "DPH") and the Orange County Health Department (herein after
referred to as "LHD") for the purposes of maintaining and promoting the advancement of public health in North
Carolina. This Agreement shall cover a period from June 1, 2020 to May 31, 2021 and shall remain in force
until the next Fiscal Year Agreement is signed except as provided for in Section J. Termination.
Now, therefore, DPH and the LHD agree that the provisions and clauses herein set forth shall be incorporated in
and constitute the terms and conditions applicable for activities involving State funding. (State funding or funds
means State, federal, and/or special funding or funds throughout this Agreement.)
A. LHD RESPONSIBILITIES
a. Performance
1. The LHD shall perform activities in compliance with applicable program rules contained in the
North Carolina Administrative Code, as well as all applicable federal and North Carolina laws and
regulations.
2. The LHD shall perform the activities specified in the Agreement Addenda for State-funded budgets.
The LHD must negotiate these Agreement Addenda in good faith to the satisfaction ofDPH
representatives as part of the Agreement execution. The LHD will meet or exceed the Agreement
Addenda deliverables unless extenuating circumstances prevail and are explained in writing and .
subsequently approved by the DPH section, branch or program.
3. The LHD shall be committed to achieve health equity, promote inclusion of all populations affected
by conditions contributing to health disparities (including race or ethnicity, sex, sexual identity, age,
disability, socioeconomic status, and geographic location), and ensure all staff, clinical and non-
clinical, participate in ongoing training focused on health equity, health disparities, and/or social
determinants of health to support individual competencies and organizational capacity to promote
health equity. The LHD shall administer and enforce all rules that have been adopted by the
Commission for Public Health or adopted by the Local Board of Health, Consolidated Human
Services Board, or Board of County Commissioners (hereinafter referred to as "LHD governing
board"), and laws that have been enacted by the North Carolina General Assembly.
4. The LHD shall provide to DPH a copy of any rules adopted, amended or rescinded by the LHD
governing board pursuant to NCGS § 130A-39 Powers and duties of a local board of health and
Public Health Ordinances adopted by the County Commissioners, within 30 days of adoption or
rescission. These rules and ordinances are to be sent to the Deputy Director ofDPH or designee.
5. The LHD shall provide formal training/orientation for its LHD governing and/or advisory board
members.
6. The LHD shall not require a client to present identification that includes a picture of the client for at
least immunization, pregnancy prevention, sexually transmitted disease and communicable disease
services.
7. LHDs shall provide or assure provision of Care Management for High-Risk Pregnancies (CMHRP),
formerly known as Pregnancy Care Management (OBCM), and Care Management for At-Risk
Children (CMARC), formerly known as Care Coordination for Children (CC4C). These services
may be funded by Medicaid, state or federal funding through Agreement Addenda, private funders
or local funds.
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a) Per federal CAPTA requirements, a notification to the county child welfare agency must
occur upon identification of an infant as "substance-affected," as defined by NC DHHS, for
the development of a Plan of Safe Care (POSC). The Plan of Safe Care requires that all
substance-affected infants be referred by the local Child Welfare Agency to the LHD for
CMARC/CC4C for care management and care coordination, regardless of insurance
coverage.
b) Medicaid requires that the LHD has the first right of refusal to provide CMHRP and
CMARC services.
c) The LHD shall use every resource including technical assistance from the regional
consultants and Women's and Children's Health (WCH) Section to resolve issues to prevent
discontinuation of services.
d) In the event that the LHD determines it cannot directly provide CMHRP and/or CMARC, the
LHD shall:
1) Notify the DPH Director in writing of the LHD's intention to discontinue the service
at least 90 days in advance of any planned action.
2) Cooperate with DPH in identifying another LHD that can provide these care
management services.
3) Provide a written plan outlining the agreed upon terms for the transition to the DPH
Director.
Discontinuation of CMHRP and CMARC without an approved transition plan may result in
the withholding of all funds to the LHD at the discretion of the DPH Director.
8. The LHD shall notify the DPH Director if there is a legal name change to the LHD, the LHD
becomes part of a consolidated human services agency, a district or a public health authority or if
there is any other governance change, or if the LHD is not subject to the NC Human Resources Act.
Notification should be in writing, within the next business day, and provide an organization chart
and any relevant supporting documents reflecting the changes.
9. The LHD shall assure DPH that expenditures of locally appropriated funds (Maintenance of Effort,
or MOE) is maintained for maternal health, child health, and family planning program activities
equal to or greater than that reported on the Staff Time Activity Report for the period July 1, 1984
through June 30, 1985. This figure is increased annually based on a federally accepted inflation
index. This revised baseline figure has been calculated and is provided as Attachment A to this
Consolidated Agreement for the LHD' s use in budget preparation.
10. The LHD shall retain financial and program records including electronic records in accordance with
the North Carolina Department of Natural and Cultural Resource's Local Government Schedules
records retention policy and in accordance with the retention of those records as described in
Section D.f. Records resulting from these services shall not be destroyed, purged or disposed of
except in accordance with the records retention policy and in accordance with State and federal law.
The State's basic records retention policy requires all grant records to be retained for a minimum of
five years or until all audit exceptions have been resolved, whichever is longer. If the contract is
subject to federal policy and regulations, record retention may be longer than five years since records
must be retained for a period of three years following submission of the final Federal Financial
Status Report, if applicable, or three years following the submission of a revised final Federal
Financial Status Report. Also, if any litigation, claim, negotiation, audit, disallowance action, or
other action involving this Agreement has been started before expiration of the five-year retention
period described above, the records must be retained until completion of the action and resolution of
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all issues which arise from it, or until the end of the regular five-year period described above,
whichever is later.
b. Data/Reporting
1. The LHD shall report client, service, encounter, and other data as specified by applicable program
rules, Agreement Addenda for State-funded budgets, and by North Carolina Administrative Code.
2. The LHD shall submit monthly reports of On-Site Wastewater activities to the On-Site Water
Protection Branch in the Environmental Health Section of DPH in the format provided by the
Environmental Health Section.
3. The LHD shall provide access to patient records to authorized staff from DPH for technical
consultation, program monitoring, and program evaluation, as specified by this Agreement,
Agreement Addenda for State-funded budgets, statute, and North Carolina Administrative Code.
4. The LHD shall provide client, service, encounter, and other data through NC's centralized automated
system known as the LHD Health Services Analysis. To ensure that such data is accurately linked to
the specific client served in a manner that results in a unique identifier from the DHHS Common
Name Data Service except as allowed by NCGS § 130A-34.2 the LHD shall allow the State to
submit ( on its behalf) the Social Security Numbers of all clients to the Social Security
Administration for verification.
5. The LHD shall share data with DPH to support public health objectives. The data will be shared in a
manner which respects the confidentiality and integrity of each party's data and protects the privacy
of individual client health information. Sharing data includes providing client information allowed as
permitted disclosures under the Health Insurance Portability and Accountability Act of 1996
(HIPAA), Public Law 104-191, HIPAA Administration Simplification Provisions Sections 261
through 264, 45 CFR 164.512.
6. The LHD shall provide Network and internet access at its facilities ( or to the county network where
desired) at a minimum speed of a full Tl line in order to:
a) Connect with critical data and surveillance systems including, but not limited to, the North
Carolina Health Alert Network (HAN), North CaroJina Electronic Disease Surveillance
System (NCEDSS), North Carolina Immunization Registry (NCIR), Local Health
Department Health Services Analysis (LHD-HSA) and Electronic Birth Registration System
(EBRS).
b) Rapidly communicate email alerts to and from DPH regarding bioterrorism and public health
topics (outbreaks, emergency alerts, etc.)
c) Access DPH training material and information used for training staff, including access to
webinars
d) Maintain a secure infrastructure for remote data entry in the LHDs
e) Report electronically all required Environmental Health Section inspection data in the format
and frequency specified by DPH. (Paper copies of inspection data are no longer accepted for
Food, Lodging, and Institutions inspections.)
The LHD may utilize security products (i.e., firewalls) of its choosing to maintain network
connectivity and security integrity. The LHD network configuration and security practices must
allow communication with systems within the DPH network.
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c. Assessments and Plans
1. The LHD shall provide to the Director of Community Health Assessment, State Center for Health
Statistics or designee:
a) A comprehensive community health assessment (CHA) at least every four years, for each
county or health district. The CHA shall be a collaborative effort with local partners inclusive
of hospitals, businesses, community partners, and the local community health coalitions and
shall include the collection and analysis of primary data at the county and district level (if
such exists), secondary data from the State Center for Health Statistics (SCHS) and other
sources, and an assessment and analysis of community resources. The CHA shall identify a
list of community health problems based on the assessment. Each identified problem shall be
prioritized and described in the narrative. The CHA will include data analysis of those
indicators listed in the Accreditation Self-Assessment Inventory, Benchmark 1, Activity 1.1.
The CHA is due on the first Monday in March following the year of assessment. Refer to
CHA tools at https://publichealth.nc.gov/lhd/index.htm
b) Community Health Improvement Plans (CHIPs) no later than six months after the completion
of the comprehensive community health assessment (CHA). The CHIPs are due by the first
Monday in September following the year of assessment.
1) A CHIP is written for each of two prioritized health problems.
2) One CHIP can be short term in nature (focus for 1-3 years), but the second CHIP
must be long term (focus for 5-10 years).
3) Each CHIP shall use best evidence interventions targeting health behaviors, the
physical environment, social and economic factors, and/or clinical care.
4) The long-term CHIP must utilize Healthy North Carolina 2030 (HNC 2030)
indicators or other evidence-based health status indicators.
5) The long-term CHIP shall include short-term and long-term interventions with a goal
of improving population health indicators (morbidity and mortality).
6) The long-term CHIP could potentially persist for several CHA cycles. With each
CHA cycle, the CHIP must be updated to demonstrate that:
a. the health problem persists and continues to be a priority
b. the current interventions are effective, or that new interventions are needed,
and
c. the interventions need to be expanded to a new target pop~lation.
7) All CHIPs shall include a plan for staffing, training, implementation, monitoring,
evaluating, and sustaining.
c) The LHD shall provide a state of the county or district health report (SOTCH) during each of
the interim years between community assessments. The SOTCH shall include progress made
on each CHIP evaluation measure. The SOTCH is due by the first Monday in March during
the years a CHA is not submitted.
d) The LHD shall make requests for variances in submission of CHA, CHIPs, and SOTCH
documents in writing in advance of the required date of submission. Emails may be sent to
the Director, Community Health Assessment, State Center for Health Statistics
cha.sotch@dhhs.nc.gov.
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B. DPH RESPONSIBILITIES
a. Training, Consultation, and Support
1. DPH shall provide training to the LHD for the LHD's response to this Agreement and to the
Agreement Addenda. Upon request, consultation will be provided by DPH to the LHD.
2. DPH shall provide coordination and support for the education and training for the public health
workforce, including developing training opportunities to achieve health equity, promote inclusion
of all populations affected by health disparities (including racial/ethnic minority groups and persons
with disabilities), and ensure all staff, clinical and non-clinical, have opportunities for training
focused on health equity, health disparities, and/or social determinants of health to support
individual competencies and organizational capacity to promote health equity.
3. DPH shall conduct liaison activities with LHDs for general problem solving and technical support.
4. DPH shall provide high-level consultation, technical assistance, and advice to local health directors
and teams via the Local and Community Support (LCS) Section. Contact the Deputy
Director/Section ChiefLCS. Broad content areas include, but are not limited to:
a) Board Relations
b) Management Teams and Staffing
c) Policy Development
d) Program Planning and Implementation
e) Quality and Performance Improvement
f) General Administrative Consultation, including consultation and technical assistance in
budgeting, fiscal, administrative and management support topic areas.
5. DPH shall provide technical assistance and consultant services, as required, for specific health
program areas, including providing guidance and consultation about specific patient clinical issues,
when requested. Contact the specific section or branch head.
6. DPH shall provide course coordination, consultation, and technical assistance on nursing practice
and standards; policies and procedures that cross programs via LCS: Local Technical Assistance and
Training (LTAT) Branch. Contact the Chief Public Health Nurse/Branch Head LTAT.
7. DPH shall provide support and consultation to the public health workforce in LHDs, including
regional public health consultants who offer technical assistance and· training on professional
development; program planning, program evaluation and quality assurance and data collection.
Contact the Chief Public Health Nurse/Branch Head LTAT.
b. Performance
1. DPH shall act as the principal liaison between the public health system and the State's Medicaid
agency on issues related to Medicaid reimbursed services provided by the State and the LHD and
shall cooperate with the State Medicaid agency to provide technical assistance, guidance, and
consultation to local health programs to ensure compliance with Medicaid policies and procedures.
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2. For services of the State Laboratory of Public Health (SLPH), DPH shall:
a) Provide free or at-cost mailers that meet the US Postal Service/DOT UN3373 Biologic
substance shipping and packaging regulations for samples submitted to the SLPH only, when
ordered via the SLPH' s web-based mailroom ordering system;
b) Assure qualified personnel to process, analyze and report test results;
c) Assure that the SLPH maintains CLIA certification;
d) Submit invoices to the LHDs via electronic means;
e) Collect interest (per NCGS § 147-86.23 Interest and penalties) and a 10% late fee as
appropriate; and
f) Provide a qualified Laboratory Director and a Technical Consultant for LHDs' laboratories
participating in the North Carolina SLPH CLIA Contract Program. Services provided by the
oversight of this personnel include training and continuing education, CLIA inspection
assistance, proficiency testing and enrollment, competency assessment, and models for
laboratory forms, procedures and policies.
3. DPH will provide support and training for the LHD to comply with all applicable laws, regulations,
and standards relating to the activities covered in this Agreement.
4. DPH shall conduct reviews, audits, and program monitoring to determine compliance with the terms
of this Agreement and its associated Agreement Addenda.
c. Data/Reporting
1. DPH shall provide automated data and surveillance systems, as available, to collect DPH program-
related data from client, service, encounter and other data on behalf of the LHDs and other public
health programs. DPH shall provide business and technical support for the automated system to the
users of this system. DPH shall notify LHDs as opportunities and/or timelines for improved or
emerging technology systems emerge.
a) LHD-Health Services Analysis: for automated reporting of clinical service data fields.
b) Environmental Health Inspection Data System-EHIDS (formerly NC BETS): for Food and
Lodging inspection and billing data
c) Electronic surveys for gathering statewide data for external funders, as required
d) Aid-to-County System for reporting all local expenditures and claiming State funds
e) The North Carolina Health Alert Network (HAN)
f) North Carolina Electronic Disease Surveillance System (NCEDSS)
g) North Carolina Immunization Registry (NCIR)
h) Electronic Birth Registration System (EBRS)
i) Others may be added as developed.
2. DPH shall be responsible in its use of data received and reviewed in its various roles as a public
health authority, health oversight agency, and business associate. Protected health information
received by DPH in its capacity as a covered entity or business associate shall be protected as
required by HIP AA (see Attachment B: Business Associate Addendum to this Consolidated
Agreement).
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3. DPH will coordinate with the NC Association of Local Health Directors to support data collection,
analysis and publication.
d. Fund Availability and Notification DPH shall provide to the LHD the Budgetary Estimates of Funding
Allocations no later than February 14 of each year to use in preparation of their local budget proposals
per current General Statute.
1. An exception is the Food & Lodging distributions required by NCGS § 130A-248(d). DPH shall
provide the Food & Lodging funding allocation on the Distribution Spreadsheet which will
accompany the Activity 874 Food & Lodging Agreement Addendum.
2. The Food & Lodging Local Health Department Request for Payment Form (DPH EH 2948) will
accompany the Agreement Addendum for Activity 874 Food & Lodging and will be provided to the
LHD no later than March 30 for the State Fiscal Year (SFY) in which payment will be made. DPH
shall disperse Food & Lodging funds to the LHD upon receipt of the executed Agreement
Addendum and the signed, completed, and approved Food & Lodging Local Health LHD Request
for Payment Form.
3. DPH shall provide a Funding Authorization document to the LHD after the receipt of the Certified
State Budget.
4. DPH shall make funds available to the LHD at the beginning of each fiscal year upon receipt of this
executed Agreement, and the executed Agreement Addenda. Funds will be dispersed in accordance
with the timely submissions of Expenditure Reports. Payment will be made to the LHD according to
the DHHS Controller's Office Aid-to-Counties Expenditure Control Schedule issued December of
each year for the following calendar year.
C. FUNDING STIPULATIONS
a. Use of Funds
1. Funding for this Agreement and all Agreement Addenda is subject to the availability of State,
federal, and Special Funds for the purpose set forth in this Agreement and the Agreement Addenda.
2. During the period of this Agreement, the LHD shall not use State, federal or Special Project funds
received under this Agreement or any Agreement Addenda to reduce locally appropriated funds as
reflected in the Local Appropriations Budget (see Section D. Fiscal Control, Paragraph h. Local
Appropriations Budget below).
b. Compliance
1. To receive funding under this Agreement, the LHD shall comply with 1 0A NCAC 46, Section .0200
Standards for Local Health Departments.
2. The LHD shall maintain authenticated employee time records to document the actual work activity
of each employee on a daily basis. The percentage of time each employee spends in each activity
shall be converted to dollars based upon the employee's salary and benefits at least on a monthly
basis. The computation shall support the charges for salaries and benefits to all federal and State
grants (as required in 2 CFR Part 200) as well as provide the documentation of detailed labor cost
per activity for preparation of Medicaid Cost Report.
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3. LHD charges/billing. The LHD shall:
a) Establish one charge per clinical/support service for all payors (including Medicaid) based on
their related costs as permitted by NCGS § 130A-39(g).
b) Bill All Payors the established charge except when billing 340B Drug Pricing Program drugs
or devices to Medicaid. All drugs or devices purchased using 340B Program must be billed to
Medicaid at the acquisition cost.
c) The LHD may accept negotiated or other agreed upon lower amounts ( e.g., the Medicaid
reimbursement rate) as payment in full.
d) Make every reasonable effort to collect charges for services through public or private third-
party payors. except where prohibited by federal regulations or State law; however, no one
shall be refused services solely because of an inability to pay.
e) All LHD fees, including environmental health fees shall be reviewed annually by the
governing body in accordance with the North Carolina Local Health Department
Accreditation Board guidance.
4. The LHD shall comply with the federal Uniform Administrative Requirements, Cost Principles, and
Audit Requirements for Federal Awards ("Uniform Guidance"), codified at 2 CFR 200, when
utilizing federal grant funds.
a) When procuring goods and services with federal grant funds, the LHD shall apply the most
restrictive rule when following federal, State, and local government procurement
requirements.
5. When administering the Women, Infants, and Children's Program (WIC), the LHD must adhere to
the requirements set forth in Section 361 of the Healthy Hunger-Free Kids Act of2010 which
amended Section 12(b) of the Richard B. Russell National School Lunch Act (NSLA), 42 USC
1760(b ). This Act requires the LHD to support full use of the federal administrative funds provided
for the WIC program. The federal administrative funds are specifically excluded from budget
restrictions or limitations including, at a minimum, hiring freezes, work furloughs and travel
restrictions.
6. The LHD agrees to execute the following consolidated Federal Certifications (Attachment C) as
applicable when receiving federal funds:
a) Certification regarding Nondiscrimination
b) Certification regarding Drug-Free Workplace Requirements
c) Certification regarding Environmental Tobacco Smoke.
d) Certification regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower
Tier Covered Transactions
e) Certification regarding Lobbying.
7. Pursuant to the Federal Funding Accountability and Transparency Act (FFATA), the LHD is
required to submit to DPH information that is reportable by DPH for all qualified sub-awardees of
federal funds. The LHD will complete and submit the Federal Funding Accountability and
Transparency Act (FF AT A) Data Reporting Requirement form provided by DPH to determine the
eligibility as a sub-awardee for reporting purposes. Information provided by the LHD will be used
by DPH to report subawards (funding authorizations) equal to or greater than $25,000 from each
federal grant.
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8. The LHD shall maintain an active registration in the federal government's System for Award
Management (SAM). The SAM registration must be updated no less than annually in order to
maintain an active status. To update the registration, the LHD must log in at the SAM home page,
wvvw.sam.gov, and follow the instructions found there.
c. Training Reimbursement
1. Subject to the availability of funds and approval of the Public Health Nursing and Professional
Development Unit, the LHD may request reimbursement for:
a) Nursing service personnel participating in Principles and Practices of Public Health Nursing
course. Reimbursement is $400 per participant upon successful completion of the course.
Reimbursement requests must be filed by the LHD to the Public Health Nursing and
Professional Development Unit within the same fiscal year the course is completed.
b) LHD Management/Supervision level staff participating in the Management and Supervision
for Public Health Professionals course. Reimbursement is $600 per participant upon
successful completion of the course. Reimbursement requests must be filed by the LHD to
the Public Health Nursing and Professional Development Unit within the same fiscal year the
course is completed.
The Training Reimbursement Form can be found at https://publichealth.nc.gov/lhd/ under the
Training Resources section or at https://ncpublichealthnursing.org/continuing-education/
2. Subject to the availability of funds and approval of the Environmental Health Section, the LHD may
request reimbursement for Centralized Intern Training (CIT) and a one-time mileage allocation.
Reimbursement requests must be filed by the LHD to the Environmental Health Section within the
same fiscal year the training is completed. (Reimbursement Request Form DHHS 4125 Centralized
Intern Training Funds Reimbursement Request is available at
https://ehs.ncpublichealth.com/ oet/index.htm)
a) For Interns attending CIT sessions, reimbursement amounts are based on the session
attended:
1) Food Protection & Facilities Track-$280
2) On-Site Water Protection Track-$560
3) Tier 2 General EH Module -$280
b) For Cross-training Registered Environmental Health Specialists (REHS) attending CIT
sessions, reimbursement amounts are based on the session attended:
1) Food, Lodging, & Institutions-$170
2) Child Care & School Sanitation-$62
3) On-site Water Protection-$450
4) Private Drinking Water Wells-$62
5) Public Swimming Pools-$62
6) Tattoo-$62
c) A one-time mileage allocation per two REHSs from the same county per training session is
based on one of the four geographical areas they are employed. Reimbursement requires
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d. Purchases
successful completion of the course and requests must be filed by the LHD within 60 days
course completion.
1) Area 1 -$57: Alamance, Caswell, Chatham, Cumberland, Duplin, Durham,
Edgecombe, Franklin, Granville, Greene, Guilford, Halifax, Hamett, Hoke, Johnston,
Lee, Lenoir, Montgomery, Moore, Nash, Orange, Person, Randolph, Sampson,
Vance, Wake, Warren, Wayne, Wilson.
2) Area 2-$170: Alexander, Alleghany, Anson, Ashe, Beaufort, Bertie, Bladen,
Brunswick, Cabarrus, Camden, Carteret, Catawba, Chowan, Columbus, Craven,
Currituck, Dare, Davidson, Davie, Forsyth, Gaston, Gates, Hertford, Hyde, Iredell,
Jones, Lincoln, Martin, Mecklenburg, New Hanover, North Hampton, Onslow,
Pamlico, Pasquotank, Pender, Perquimans, Pitt, Richmond, Robeson, Rockingham,
Rowan, Scotland, Stanly, Stokes, Surry, Tyrrell, Union, Washington, Watauga,
Wilkes, Yadkin.
3) Area 3 -$283: Avery, Buncombe, Burke, Caldwell, Cleveland, Haywood,
Henderson, Jackson, Madison, McDowell, Mitchell, Polk, Rutherford, Transylvania,
Yancey.
4) Area 4-$396: Cherokee, Clay, Graham, Macon, Swain.
1. Equipment is a type of fixed asset consisting of specific items of property that: ( 1) is tangible in
nature; (2) has a life longer than one year; and (3) has a significant value.
a) For Inventory Purposes
1) Equipment must be accounted for in accordance with the North Carolina Department
of State Treasurer's Policy Manual for Local Government, Chapter 20, Capital
Assets.
2) All equipment with an acquisition cost of $500 or more which was purchased with
Women, Infants and Children (WIC) Program Funds, prior to January 1, 2018 will be
inventoried with the Women's and Children's Health Section. The Local Agency is
responsible for assigning a fixed asset number and applying a fixed asset tag to
equipment purchased by the Local Agency, using WIC funds, after January 1, 2018.
Within 60 days of the purchase, the Local Agency will provide to the Nutrition
Services Branch a written report of the purchase, including a description of the item
purchased, serial number, fixed asset tag number, and a copy of the bill of sale.
b) For Prior Approval Purposes
1) Except for WIC, all equipment purchased or leased with an acquisition cost
exceeding $2,500, where there is an option to purchase with State/federal funds, the
purchase or lease must receive prior written approval from the appropriate Section
and Branch within DPH. [See Subparagraph 2 below for WIC requirements.] For
those purchased with Public Health Preparedness & Response Branch funds only, any
purchase exceeding $2,500 per invoice shall be treated as a single purchase for prior
approval purposes. [For example, on one invoice, the LHD purchases a computer,
monitor, and printer totaling more than $2,500, or purchases six computers at $500
each.]
2) For WIC, all computer and medical equipment purchased or leased, must receive
prior written approval from the Branch regardless of cost. In addition, all other
tangible assets (non-computer/medical) with an acquisition cost exceeding $500 must
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receive prior approval. Computer accessories, such as keyboards and monitors, do not
require approval.
c) For Accounting Purposes
1) The LHD must utilize the depreciation schedule provided by the State for all assets
with an acquisition cost of $5,000 or greater. The accumulated depreciation shall be
recorded in the general fixed assets account group.
2. Prior approval required for purchases other than equipment:
a) For Public Health Preparedness & Response Branch funds, purchases for meals and
refreshments must receive prior written approval from the PHP&R Branch.
b) The use of Women's and Children's Health Medicaid fees for capital improvements requires
prior written approval from the Women's and Children's Health Section.
D. FISCAL CONTROL
a. The LHD shall comply with the Local Government Budget and Fiscal Control Act, North Carolina
General Statute Chapter 159, Article 3.
1. The LHD shall maintain a purchasing and procurement system in accordance with generally
accepted accounting practices and procedures set forth by the Local Government Commission.
b. The LHD shall execute written agreements with all parties who invoice the LHD for payment for the
provision of services to patients. Exceptions may be permitted in cases where the patient has a
preference for a non-contracted provider and that provider verbally agrees to abide by program
requirements and to accept program payment as payment in full.
c. The LHD, when subcontracting, must meet the following conditions:
1. The LHD is not relieved of any of the duties and responsibilities provided in this Agreement.
2. The LHD will not enter into a subcontractual financial assistance agreement with any entity on the
North Carolina Office of State Budget and Management (OSBM) "Suspension of Funding" list
(SOFL) and shall withhold funds not yet disbursed until the entity has been removed from the SOFL.
SOFLs are available on the OSBM website (https://w'Ww.osbm.nc.gov/management/grants).
3. The subcontractor will agree to abide by the standards contained herein or to provide such
information as to allow the LHD to comply with these standards.
4. The subcontractor shall be subject to all conditions of this contract and of any subsequent Agreement
Addenda for which they perform work on behalf of the LHD.
5. The subcontractor will agree to allow State and federal authorized representatives' access to any
records pertinent to its role as a subcontractor of the LHD.
6. Upon request, the LHD will make available to the State a copy of subcontracts supported with State
or federal funds.
d. The LHD must receive prior written approval from the State to subcontract when any of the following
conditions exist:
1. The LHD proposes to subcontract to a single entity 50 percent or more of the total State and federal
funds made available through this Agreement.
2. The LHD proposes to subcontract 50 percent or more, or $50,000, whichever is greater, of the total
State and federal funds made available through this Agreement for any Agreement Addendum.
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3. The LHD proposes to subcontract for services in the Women, Infants and Children (WIC) Program.
e. The LHD shall mail a signed copy of all public health Funding Authorization documents to the DPH
Budget Office, 1931 Mail Service Center, Raleigh, NC 27699-1931.
f. The LHD shall retain a copy of all Funding Authorization documents, the monthly certified electronic
printed screen of the Expenditure Reports with any amendments (via the Aid-to-Counties Database),
Consolidated Agreement, Agreement Addenda, Agreement Addendum Revisions and other financial
records in accordance with the current Records Disposition Schedule for Local Health Departments
issued by the North Carolina Department of Natural and Cultural Resources and located on their website
at: https://archives.ncdcr.gov/documents/local-health-departments-schedule
g. Audits/Monitoring: The county or the LHD shall have an annual audit performed in accordance with
the Single Audit Act of 1984 (with amendment in 1996) and 2 CFR Part 200. The audit report shall be
submitted to the Local Government Commission (LGC) by the County Administration (if single county
LHD) or the District Health Department or Public Health Authority (if so organized) within six months
following the close of the Agreement. Audit findings referred to the DHHS Internal Audit Office by
LGC will be investigated and findings verified by the DHHS Controller's Office staff with assistance of
DPH Program Staff.
h. Local Appropriations Budget: The LHD shall prepare and maintain a Local Appropriations Budget
(reflecting the plans to use local appropriations or earned fees) for each Agreement Addendum in a
manner consistent with instructions provided in funding-specific budgetary guidance from DPH and the
specific guidance from the respective programs.
1. Local Earned Revenues Budgeting and Reporting: The LHD shall observe the following conditions
when budgeting and reporting Local Earned Revenues:
1. Locally appropriated funds may not be withdrawn due to fee collection greater than projected in the
budget or due to new grant funding except during the last two months of the fiscal year to allow the
county to manage end of year budget close out.
2. All earned revenue ( officially classified as local funds) must be budgeted and spent in the program
that earned it except:
a) Revenue generated by Women's and Children's Health (WCH) Section Programs may be
budgeted and expended ( consequently reported) in any WCH Section Program, unless a
specific Agreement Addendum has a more restrictive requirement.
b) Revenue generated by a local clinic or program that has no State-funded budget (no State or
federal funds) shall be budgeted and associated expenditures reported in a State Program
Activity that most closely matches the deliverables of the respective State program. This
process will enable the collection of total expenditures in public health per program.
3. The LHD shall not use personal health program funds to support environmental health programs nor
use environmental health program funds to support personal health programs.
4. Use of program income generated by the expenditure of federal categorical funds will be governed
by applicable federal regulations, including, but not limited to, 2 CFR Part 200.
5. A local account shall be maintained for unexpended earned revenues (i.e., Title XIX fees, private
insurance or private pay [cash]). Accounts shall be maintained in sufficient detail to identify the
program source generating the fees.
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6. The amount of Title XIX fees budgeted and expended in FY 2020-2021 must equal or exceed the
amount of Title XIX revenues earned during FY 2018-2019. The State will not approve program
activity budgets that do not include an amount of Title XIX fees sufficient to meet the requirements
of this section. The State may waive this requirement if the LHD provides sufficient justification.
J. Aid-to-Counties Database and Expenditure Reports: The LHD shall submit a monthly report of
actual State, federal and local expenditures to the DHHS Controller's Office via the Aid-to-Counties
Database (ATC).
1. Specific ATC instructions and training will be provided by L TAT to LHDs and will include
guidance for reporting local programs, examples include but are not limited to: Dental Clinic and
Primary Care.
2. DPH shall produce an annual ATC report in order to provide information reported that summarize
LHD and statewide analysis and trending, including per-capita analysis, when applicable. This
report will be produced in collaboration with NCALHD and will be posted publicly on the DPH
website.
3. The LHD shall submit to the DHHS Controller's Office a monthly Expenditure Report of the
pertinent month's actual expenditures for all programs via ATC. The Office of the Controller's Aid-
to-Counties Expenditure Control Schedule, published annually in December for the next calendar
year, provides the submission dates for these expenditures. This schedule allows the LHD at least
seven days to enter the pertinent month's expenditures into the Aid-to-Counties Database. Failure to
meet the reporting deadline will result in the exclusion of those expenditures for that month. The
LHD must submit these monthly Expenditure Reports via the Aid-to-Counties Database
consecutively throughout the Agreement period.
The health director and the finance officer will approve the monthly Expenditure Report in the Aid-
to-Counties Database and the system will alert the staff in the DHHS Controller's Office that
expenditures have been approved and certified. The "Certification" verifies that the total State and
federal expenditures reported are valid for the pertinent month's actual expenditures. Local
expenditures are part of the Expenditure Report but are not included in the amount verified in the
"Certification." Local appropriations must be reported monthly along with the State and federal
expenditures. Funding is based on an allocation method, not a contract method, and counties receive
reimbursement for services provided during one month in the following month.
4. The final Expenditure Report for the SFY, the last service month to be paid in the SFY, will be May
services which are reported and paid in June. (Services provided in June and reported in July will be
paid out of the next SFY.)
5. When Agreement Addenda are supported by federal funding or grants that do not coincide with the
State fiscal year, care must be taken to be attentive to the service month and payment months for
each grant as well as the ending liquidation date for each grant. Expenditures of federal funds must
be reported according to the funding period for a grant. For each grant, the Budgetary Estimate
document and the Funding Authorization document will have service and payment month dates
listed. Failure to report expenditures after the payment period ends may result in non-payment.
6. The LHD shall have the opportunity to submit amended expenditure reports in the month following
discovery of the error. The LHD shall not wait to submit all adjustments with the invoice submitted
to the Office of the Controller at the end of May as that will not allow sufficient time for verification
of the adjustments before the last payment in the State Fiscal Year.
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a) In accordance with Paragraph D.j.4 above, the LHD must keep current on reporting
adjustments against federal funds to ensure such adjustments are received in time to be paid
within the grant's payment period.
b) The LHD shall review their prior reimbursement claims against payments monthly.
c) Amended expenditure reports must be submitted no later than the next reporting date after
the grant period ends in order to be paid unless an exception is approved by the DPH Budget
Office.
d) Any overpayments identified by either the State or the LHD will be adjusted out of the next
month's claim for reimbursement by the DHHS Controller's Office or by submitting a check
to DHHS for payment if it is the last month of the fiscal year or the federal grant is closed.
There is no provision to carry forward funds from one State Fiscal Year to another; therefore,
any adjustment not included in the June payment ( or earlier if the grant period expires during
the State Fiscal Year) shall be paid from local funds.
E. PERSONNEL POLICIES
a. The LHD shall adhere to and fully comply with State and county personnel policies as applicable.
b. Environmental Health Specialists employed by the LHD shall be delegated authority by the State to
administer and enforce State environmental health rules and laws as directed by the State pursuant to
NCGS § 130A-4 Administration. This delegation shall be done according to 15A NCAC 010 .0101
Scope of Delegated Authority.
1. The LHD is responsible for sending their newly employed environmental health specialists (interns)
to centralized intern training within 180 days from date of employment.
2. Arrangements for centralized intern training for newly employed environmental health specialists
will be handled by the DPH Education and Training Staff.
3. The LHD, when contracting with an environmental health specialist (EHS) employed by another
entity, shall be responsible for ensuring that all original documents/public records ( e.g., permits,
inspection reports, correspondence) generated by the contracted EHS be maintained by the LHD. All
contracts covering this work shall stipulate that the contracted EHS shall be available for
consultation with the public concerning work performed under the contract.
c. The LHD shall comply with lOA NCAC 46 .0301 Minimum Standard Health Department Staffing and
shall ensure that all nursing staff who provide public health services funded by this Agreement comply
with this rule.
d. The LHD shall complete the State Certifications (Attachment D) regarding its compliance with
E-Verify, its eligibility status as a contractor, and that its officers have not violated any State or federal
Securities Acts.
F. CONFIDENTIALITY
a. The LHD shall protect the confidentiality of all information, data, instruments, documents, studies, or
reports received under this agreement in accordance with the standards of the DHHS privacy and
security policies, applicable local laws, State regulations, and federal regulations including: the Privacy
Rule at 45 C.F.R. Parts 160 and 164, subparts A and E, Security Standards at 45 C.F.R. Parts 160, 162
and 164, subparts A and C ("the Security Rule"), and the applicable provisions of the Health
Information Technology for Economic and Clinical Health Act (HITECH).
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b. All information obtained by LHD personnel in connection with the provision of services or other
activity under this Agreement shall be confidential, except as may be required or allowed by law or
otherwise permitted by this agreement. Information may be disclosed in summary, statistical, or other
form which does not directly or indirectly identify particular individuals. Otherwise, information shall
not be disclosed or made available to any individual or organization without the prior written consent of
the client or responsible person, except as may be required or allowed by law or otherwise permitted by
this agreement.
c. LHD employees must sign confidentiality agreements documenting the knowledge of, and the
agreement to maintain personal and medical confidentiality.
G. CIVIL RIGHTS
a. The LHD shall assure that no person, on the grounds of race, color, age, religion, sex, marital status,
immigration status, national origin, or disability be excluded from participation in, be denied the benefits
of, or be subjected to discrimination under any program or activity covered by this Agreement.
b. The American with Disabilities Act 1990 (ADA) makes it unlawful to discriminate in employment
against a qualified individual with a disability and outlaws discrimination against individuals with
disabilities in State and local government services and public accommodations. The LHD certifies that it
and its principals and subcontractors will comply with regulations in ADA Title I (Employment), Title II
(Public Services), and Title III (Public Accommodations) in fulfilling the obligations under this
Agreement.
c. As required by Title VI of the Civil Rights Act, the LHD, because it receives federal funds, must
provide interpreter services at no charge to Limited English Proficiency clients in all programs and
services offered by the LHD.
H. LHD DISBURSEMENT OF FUNDS
a. DPH shall disburse funds to the LHD on a monthly basis; monthly disbursements for each program
activity will be based on monthly expenditures reported.
b. Total payment by program Activity is limited to the total amount listed on the Funding Authorization
document and any Funding Authorization revision documents received after the initial notification.
c. Final payments for the State Fiscal Year will be made based on the final monthly Expenditure Report
which is due as delineated per the Controller's Office's Aid-to-Counties Payment Schedule.
I. AMENDMENT OF AGREEMENT
Amendments, modifications, or waivers of this Agreement may be made at any time by mutual consent of
all parties. Amendments shall be in writing and signed by appropriate authorities.
J. PROVISION OF TERMINATION
a. Either party may terminate this Agreement for reasons other than non-compliance upon 60 days written
notice. If termination occurs, the LHD shall receive payment only for allowable expenditures.
b. In the event of termination, DPH may withhold payment to the LHD until DPH can determine whether
the LHD is entitled to further payment or whether DPH is entitled to a refund.
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K. COMPLIANCE
a. DPH shall respond to non-compliance with all terms ofthis Agreement as follows:
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1. Upon determination of non-compliance, DPH shall give the LHD 60 days written notice to come
into compliance. If the deficiency is corrected, the LHD shall submit a written report to DPH that
sets forth the corrective action taken.
2. If the above deficiency is not corrected to the satisfaction ofDPH after the 60-day period,
disbursement of funds for the particular activity may be temporarily suspended pending negotiation
of a plan of corrective action.
3. If the deficiency is not corrected to the satisfaction ofDPH within 90 days of the written notice in
Section K.a.1, program funds may be permanently suspended until the LHD can provide evidence
that the deficiency has been corrected.
4. In the event of the LHD's non-compliance with clauses of this Agreement, DPH may cancel,
terminate, or suspend this Agreement in whole or in part and the LHD may be declared ineligible for
further DPH contracts or agreements. Such terminations for non-compliance shall not occur until the
provisions of Section K.a. l through K.a.3 have been followed, documented, and have failed to
correct the deficiency.
b. Monitoring -"Omni-Circular" 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles,
and Audit Requirements for Federal Awards, Subpart F Audit Requirements requires that pass-through
entities monitor the activities of their subcontractors as necessary to ensure that federal awards are used
for authorized purposes in compliance with laws, regulations and the provision of contracts or grant
agreements and that performance goals are achieved.
North Carolina establishes related monitoring requirements for State funds received by subrecipients in
NCGS § 143C-6-23 State grant funds: administration; oversight and reporting requirements. Also, DPH
must perform monitoring as required in the DHHS Policy and Procedure Manual entitled Monitoring of
Programs dated August 1, 2002 and its DPH Subrecipient Monitoring Plan dated October2016.
Additionally, the LHD is required under 2 CFR, Part 200 Subpart F, NCGS § 143C-6-23, and_ NCGS §
159-34 Annual independent audit; rules and regulations, to perform monitoring of its subrecipients and
to maintain records to support such monitoring activities and results. Accordingly, the LHD shall
participate fully in monitoring by DPH and shall appropriately monitor its sub-recipients to the extent
necessary based on the assessed level of risk.
In witness whereof, the LHD and the Division of Public Health have executed this Amendment in duplicate
originals, one of which is to be retained by each of the parties.
Orange County Health Department
Health or Human Services Director
Finance Officer
County Official
(when locally required)
Date
Date
Date
North Carolina Department of
Health and Human Services,
Division of Public Health
Division Director Date
N/A
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ATTACHMENT A
LHD MAINTENANCE OF EFFORT SCHEDULE
Local Health Department MOE Baseline Updated Baseline Local Health Department MOE Baseline Updated Baseline
1985 CPI * 2020-21 1985 CPI * 2020-21
Alamance 215,751 526,218 Jackson 11,822 28,834
Albemarle District 51,320 125,169 Johnston 196,475 479,203
Alexander 33,308 81,237 Jones 22,851 55,734
Anson 27,096 66,086 Lee 57,470 140,169
Appalachian District 56,663 138,200 Lenoir 120,667 294,307
Beaufort 63,029 153,727 Lincoln 78,475 191,401
Bladen 19,564 47,716 Macon 27,277 66,529
Brunswick 122,285 298,253 Madison 55,718 135,897
Buncombe 166,104 405,127 MTW District 97,748 238,407
Burke 83,689 204,118 Mecklenburg 375,712 916,362
Cabarrus 250,406 610,740 Montgomery 24,389 59,484
Caldwell 59,226 144,452 Moore 36,243 88,397
Carteret 16,843 41,080 Nash 124,412 303,440
Caswell 31,809 77,582 New Hanover 128,664 313,811
Catawba 127,542 311,075 Northampton 71,678 174,822
Chatham 50,121 122,245 Onslow 63,147 154,016
Cherokee 11,705 28,548 Orange 258,834 631,296
Clay 1,580 3,853 Pamlico 11,162 27,224
Cleveland 243,917 594,914 Pender 0 0
Columbus 85,858 209,408 Person 42,878 104,579
Craven 113,647 277,185 Pitt 164,404 400,981
Cumberland 458,294 1,117,778 Polk** TBD TBD
Dare 22,597 55,115 Randolph 81,302 198,296
Davidson 100,199 244,385 Richmond 50,348 122,800
Davie 38,546 94,015 Robeson 225,422 549,804
Duplin 84,922 207,124 Rockingham 157,370 383,825
Durham 439,506 1,071,955 Rowan 178,268 434,795
Edgecombe 157,941 385,218 RPM District** 48,315 117,841
Forsyth 508,138 1,239,349 Sampson 37,229 90,801
Foothills District** TBD TBD Scotland 12,388 30,213
Franklin 65,012 158,564 Stanly 23,625 57,621
Gaston 342,765 836,003 Stokes 41,687 101,675
Graham 3,949 9,632 Surry 49,658 121,116
Granville-Vance 170,160 415,020 Swain 10,674 26,033
Greene 78,527 191,527 Toe River District 49,658 121,116
Guilford 1,605,509 3,915,837 Transylvania 66,417 161,992
Halifax 118,024 287,861 Union 25,573 62,372
Harnett 69,651 169,878 Wake 758,321 1,849,545
Haywood 82,684 201,666 Warren 8,551 20,855
Henderson 109,750 267,681 Wayne 271,847 663,035
Hoke 25,698 62,678 Wilkes 73,909 180,263
Hyde 12,355 30,133 Wilson 59,617 145,407
Iredell 36,698 89,508 Yadkin 20,687 50,456
TOTAL: $10,583,276 $25,812,611
Citation: 130A-4.1; Consolidated Agreement clause A.a.9.
Notes: * Adjusted for inflation, January 1985 through October 2019, based upon changes in Consumer Price Index (CPI). Adjustment factor equals
243.9%. Reference for calculating CPI changes: https://www.bls.gov/data/inflation_calculator htm
** RPM District's baselines will be divided between Foothills District and Polk. A replacement Attachment A will be provided as an
amendment to this Consolidated Agreement to the affected LHDs.
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ATTACHMENTB
BUSINESS ASSOCIATE ADDENDUM TO CONSOLIDATED AGREEMENT
This Agreement is made effective July 1, 2020, by and between Orange County Health Department
("Covered Entity") and the North Carolina Department of Health and Human Services, Division of Public
Health ("Business Associate") ( collectively the "Parties").
1. BACKGROUND
a. Covered Entity and Business Associate are parties to a Memorandum of Understanding, entitled
"FY 2021 Consolidated Agreement" (the "MOU"), whereby Business Associate agrees to perform
certain services for or on behalf of Covered Entity.
b. Covered Entity is an LHD in the State of North Carolina that has been designated in whole or in part by
as a "covered entity" for purposes of the HIP AA Privacy Rule.
c. The relationship between Covered Entity and Business Associate is such that the Parties believe
Business Associate is or may be a "business associate" within the meaning of the HIPAA Privacy Rule.
d. The Parties enter into this Business Associate Addendum to the MOU with the intention of complying
with the HIP AA Privacy Rule provision that a covered entity may disclose protected health information
to a business associate and may allow a business associate to create or receive protected heath
information on its behalf, if the covered entity obtains satisfactory assurances that the business associate
will appropriately safeguard the information.
2. DEFINITIONS
Unless some other meaning is clearly indicated by the context, the following terms shall have the following
meaning in this Agreement:
a. "Electronic Protected Health Information" shall have the same meaning as the term "electronic protected
health information" in 45 C.F.R. § 160.103.
b. "HIPAA" means the Administrative Simplification Provisions, Sections 261 through 264, of the federal
Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, as modified and
amended by the Health Information Technology for Economic and Clinical Health ("HITECH") Act,
Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of
2009, Public Law 111-5.
c. "Individual" shall have the same meaning as the term "individual" in 45 C.F.R. § 160.103 and shall
include a person who qualifies as a personal representative in accordance with 45 C.F.R. § 164.502(g).
d. "Privacy Rule" shall mean the Standards for Privacy of Individually Identifiable Health Information at
45 C.F.R. Part 160 and Part 164.
e. "Protected Health Information" shall have the same meaning as the term "protected health information"
in 45 C.F.R. § 160.103, limited to the information created or received by Business Associate from or on
behalf of Covered Entity.
f. "Required By Law" shall have the same meaning as the term "required by law" in 45 C.F.R. § 164.103.
g. "Secretary" shall mean the Secretary of the United States Department of Health and Human Services or
the person to whom the authority involved has been delegated.
h. Unless otherwise defined in this Agreement, terms used herein shall have the same meaning as those
terms have in the Privacy Rule.
3. OBLIGATIONS OF BUSINESS ASSOCIATE
a. Business Associate agrees to not use or disclose Protected Health Information other than as permitted or
required by this Agreement or as Required By Law.
b. Business Associate agrees to use appropriate safeguards and comply, where applicable, with subpart C
of 45 C.F.R. Part 164 with respect to electronic protected health information, to prevent use or
disclosure of the Protected Health Information other than as provided for by this Agreement.
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c. Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to
Business Associate of a use or disclosure of Protected Health Information by Business Associate in
violation of the requirements of this Agreement.
d. Business Associate agrees to report to Covered Entity any use or disclosure of the Protected Health
Information not provided for by this Agreement of which it becomes aware, including breaches of
unsecured protected health information as required by 45 C.F.R. § 164.410.
e. Business Associate agrees, in accordance with 45 C.F.R. § 164.502(e)(l) and§ 164.308(b)(2), to ensure
that any subcontractors that create, receive, maintain, or transmit protected health information on behalf
of Business Associate agree to the same restrictions and conditions that apply to Business Associate
with respect to such information.
f. Business Associate agrees to make available protected health information as necessary to satisfy
Covered Entity's obligations in accordance with 45 C.F.R. § 164.524.
g. Business Associate agrees to make available Protected Health Information for amendment and
incorporate any amendment(s) to Protected Health Information in accordance with 45 C.F.R. § 164.526.
h. Unless otherwise prohibited by law, Business Associate agrees to make internal practices, books, and
records relating to the use and disclosure of Protected Health Information received from or created or
received by Business Associate on behalf of, Covered Entity available to the Secretary for purposes of
the Secretary determining Covered Entity's compliance with the Privacy Rule.
1. Business Associate agrees to make available the information required to provide an accounting of
disclosures of Protected Health Information in accordance with 45 C.F.R. § 164.528.
4. PERMITTED USES AND DISCLOSURES
a. Except as otherwise limited in this Agreement or by other applicable law or agreement, if the MOU
permits, Business Associate may use or disclose Protected Health Information to perform functions,
activities, or services for, or on behalf of, Covered Entity as specified in the MOU, provided that such
use or disclosure:
1) would not violate the Privacy Rule if done by Covered Entity; or
2) would not violate the minimum necessary policies and procedures of the Covered Entity.
b. Except as otherwise limited in this Agreement or by other applicable law or agreements, if the MOU
permits, Business Associate may disclose Protected Health Information for the proper management and
administration of the Business Associate or to carry out the legal responsibilities of the Business
Associate, provided that:
1) the disclosures are Required By Law; or
2) Business Associate obtains reasonable assurances from the person to whom the information is
disclosed that it will remain confidential and will be used or further disclosed only as Required By
Law or for the purpose for which it was disclosed to the person, and the person notifies the Business
Associate of any instances of which it is aware in which the confidentiality of the information has
been breached.
c. Except as otherwise limited in this Agreement or by other applicable law or agreements, if the MOU
permits, Business Associate may use Protected Health Information to provide data aggregation services
to Covered Entity as permitted by 45 C.F.R. § 164.504(e)(2)(i)(B).
d. Notwithstanding the foregoing provisions, Business Associate may not use or disclose Protected Health
Information if the use or disclosure would violate any term of the MOU or other applicable law or
agreements.
5. TERM AND TERMINATION
a. Term. This Agreement shall be effective as of the effective date stated above and shall terminate when
the MOU terminates.
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b. Termination for Cause. Upon Covered Entity's knowledge of a material breach by Business Associate,
Covered Entity may, at its option:
1) Provide an opportunity for Business Associate to cure the breach or end the violation, and terminate
this Agreement and services provided by Business Associate, to the extent permissible by law, if
Business Associate does not cure the breach or end the violation within the time specified by
Covered Entity;
2) Immediately terminate this Agreement and services provided by Business Associate, to the extent
permissible by law; or
3) If neither termination nor cure is feasible, report the violation to the Secretary as provided in the
Privacy Rule.
c. Effect of Termination.
1) Except as provided in paragraph (2) of this section or in the MOU or by other applicable law or
agreements, upon termination of this Agreement and services provided by Business Associate, for
any reason, Business Associate shall return or destroy all Protected Health Information received
from Covered Entity or created or received by Business Associate on behalf of Covered Entity. This
provision shall apply to Protected Health Information that is in the possession of subcontractors or
agents of Business Associate. Business Associate shall retain no copies of the Protected Health
Information.
2) In the event that Business Associate determines that returning or destroying the Protected Health
Information is not feasible, Business Associate shall provide to Covered Entity notification of the
conditions that make return or destruction not feasible. Business Associate shall extend the
protections of this Agreement to such Protected Health Information and limit further uses and
disclosures of such Protected Health Information to those purposes that make the return or
destruction infeasible, for so long as Business Associate maintains such Protected Health
Information.
6. GENERAL TERMS AND CONDITIONS
a. This Agreement amends and is part of the MOU.
b. Except as provided in this Agreement, all terms and conditions of the MOU shall remain in force and
shall apply to this Agreement as if set forth fully herein.
c. In the event of a conflict in terms between this Agreement and the MOU, the interpretation that is in
accordance with the Privacy Rule shall prevail. In the event that a conflict then remains, the MOU terms
shall prevail so long as they are in accordance with the Privacy Rule.
d. A breach of this Agreement by Business Associate shall be considered sufficient basis for Covered
Entity to terminate the MOU for cause.
Orange County Health Department
Health or Human Services Director Date
North Carolina Department of
Health and Human Services,
Division of Public Health
Division Director Date
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ATTACHMENT C
FEDERAL CERTIFICATIONS
The undersigned states that:
1. He or she is the duly authorized representative of the Contractor named below;
2. He or she is authorized to make, and does hereby make, the following certifications on behalf of the Contractor,
as set out herein:
a. The Certification Regarding Nondiscrimination;
b. The Certification Regarding Drug-Free Workplace Requirements;
c. The Certification Regarding Environmental Tobacco Smoke;
d. The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions; and
e. The Certification Regarding Lobbying;
3. He or she has completed the Certification Regarding Drug-Free Workplace Requirements by providing the
addresses at which the contract work will be performed;
4. [Check the applicable statement]
D He or she bas completed the attached Disclosure of Lobbying Activities because the Contractor has made,
or has an agreement to make, a payment to a lobbying entity for influencing or attempting to influence an
officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee
of a Member of Congress in connection with a covered federal action;
OR
D He or she bas not completed the attached Disclosure of Lobbying Activities because the Contractor has not
made, and has no agreement to make, any payment to any lobbying entity for influencing or attempting to
influence any officer or employee of any agency, any Member of Congress, any officer or employee of
Congress, or any employee of a Member of Congress in connection with a covered Federal action.
5. The Contractor shall require its subcontractors, if any, to make the same certifications and disclosure.
Signature Title
Orange County Health Department
Contractor [Organization's] Legal Name Date
[This Certification must be signed by a representative of the Contractor who is authorized to sign contracts.]
I. Certification Regarding Nondiscrimination
The Contractor certifies that it will comply with all Federal statutes relating to nondiscrimination. These include but are
not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis ofrace,
color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681-1683, and
1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as
amended (29 U.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of
1975, as amended (42 U.S.C. §§6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office
and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as
amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Title VIII of the Civil Rights Act of
1968 (42 U.S.C. §§3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (h)
the Food Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i)
the requirements of any other nondiscrimination statutes which may apply to this Agreement.
X
DocuSign Envelope ID: B7CC8492-1A0C-48C3-B890-562DC3D404A4
4/21/2020
Orange County Health Director
Consolidated Agreement FY21
II. Certification Regarding Drug-Free Workplace Requirements
1. The Contractor certifies that it will provide a drug-free workplace by:
Page 22 of27
a. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession or use of a controlled substance is prohibited in the Contractor's workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
b. Establishing a drug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The Contractor's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
c. Making it a requirement that each employee be engaged in the performance of the agreement be given a
copy of the statement required by paragraph (a);
d. Notifying the employee in the statement required by paragraph (a) that, as a condition of employment
under the agreement, the employee will:
(1) Abide by the terms of the statement; and
(2) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace
no later than five days after such conviction;
e. Notifying the LHD within ten days after receiving notice under subparagraph (d)(2) from an
employee or otherwise receiving actual notice of such conviction;
f. Taking one of the following actions, within 30 days ofreceiving notice under subparagraph (d)(2), with
respect to any employee who is so convicted:
(1) taking appropriate personnel action against such an employee, up to and including
termination; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal, State, or local health, law enforcement, or other
appropriate agency; and
g. Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs (a), (b), (c), (d), (e), and (f).
2. The sites for the performance of work done in connection with the specific agreement are listed below (list all sites; add
additional pages if necessary):
Street Address No. 1: ______________________________ _
City, State, Zip Code: _____________________________ _
Street Address No. 2: ______________________________ _
City, State, Zip Code: _____________________________ _
3. Contractor will inform the LHD of any additional sites for performance of work under this agreement.
4. False certification or violation of the certification may be grounds for suspension of payment, suspension or termination
of grants, or government-wide Federal suspension or debarment. 45 C.F.R. 82.510.
ill. Certification Regarding Environmental Tobacco Smoke
Public Law 103-227, Part C-Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act), requires
that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used
see final page for address #3Chapel Hill, NC 27516
2501 Homestead Road
Hillsborough, NC 27278
300 West Tryon Street
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Consolidated Agreement FY2 l Page 23 of27
routinely or regularly for the provision of health, day care, education, or library services to children under the age of 18, if
the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract,
loan, or loan guarantee. The law does not apply to children's services provided in private residences, facilities funded solely
by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply
with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000.00 per day and/or the
imposition of an administrative compliance order on the responsible entity.
The Contractor certifies that it will comply with the requirements of the Act. The Contractor further agrees that it will
require the language of this certification be included in any subawards that contain provisions for children's services and
that all subgrantees shall certify accordingly.
IV. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions
Instructions
[The phrase "prospective lower tier participant" means the Contractor.]
1. By signing and submitting this document, the prospective lower tier participant is providing the certification set out
below.
2. The certification in this clause is a material representation of the fact upon which reliance was placed when this
transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an
erroneous certification, in addition to other remedies available to the Federal Government, the LHD or agency with
which this transaction originate may pursue available remedies, including suspension and/or debarment.
3. The prospective lower tier participant will provide immediate written notice to the person to whom this proposal is
submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted
or has become erroneous by reason of changed circumstances.
4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant,"
"person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause,
have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549, 45
CFR Part 76. You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those
regulations.
5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction
be entered into, it shall not knowingly enter any lower tier covered transaction with a person who is debarred, suspended,
determined ineligible or voluntarily excluded from participation in this covered transaction unless authorized by the
LHD or agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this document that it will include the clause titled
"Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered
Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered
transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered
transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from covered transaction, unless it
knows that the certification is erroneous. A participant may decide the method and frequency by which it determines
the eligibility of its principals. Each participant may, but is not required to, check the Non-procurement List.
8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render
in good faith the certification required by this clause. The knowledge and information of a participant is not required to
exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
9. Except for transactions authorized in paragraph 5 of these instructions, if a participant in a covered transaction
knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or
voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal
Government, the LHD or agency with which this transaction originated may pursue available remedies, including
suspension, and/or debarment.
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Consolidated Agreement FY21 Page 24 of27
Certification
a. The prospective lower tier participant certifies, by submission of this document, that neither it nor its principals is
presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation
in this transaction by any Federal department or agency.
b. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such
prospective participant shall attach an explanation to this proposal.
V. Certification Regarding Lobbying
The Contractor certifies, to the best of his or her knowledge and belief, that:
1. No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal
contract, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative
agreement.
2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with this Federally funded contract, grant, loan, or
cooperative agreement, the undersigned shall complete and submit Standard Form SF-LLL, "Disclosure of Lobbying
Activities," in accordance with its instructions.
3. The undersigned shall require that the language of this certification be included in the award document for subawards
at all tiers (including subcontracts, sub grants, and contracts under grants, loans, and cooperative agreements) who
receive federal funds of$100,000.00 or more and that all subrecipients shall certify and disclose accordingly.
4. This certification is a material representation of fact upon which reliance was placed when this transaction was made or
entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by
Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil
penalty of not less than $10,000.00 and not more than $100,000.00 for each such failure.
VI. Disclosure of Lobbying Activities
Instructions
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the
initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. section
13 52. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing
or attempting to influence an officer or employee of any agency, a Member of Congress, an.officer or employee of Congress,
or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation
Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial
filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget
for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the
outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the
information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last
previously submitted report by this reporting entity for this covered Federal action.
4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known.
Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or subaward
recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include
but are not limited to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in Item 4 checks "Subawardee", then enter the full name, address, city, state and zip
code of the prime Federal recipient. Include Congressional District, if known.
DocuSign Envelope ID: B7CC8492-1A0C-48C3-B890-562DC3D404A4
Consolidated Agreement FY21 Page 25 of27
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level
below agency name, if known. For example, Department of Transportation, United States Coast Guard.
'
7. Enter the Federal program name or description for the covered Federal action (Item 1). If known, enter the full Catalog
of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal Identifying number available for the Federal action identified in Item 1 (e.g., Request
for Proposal (RFP) number, Invitation for Bid (IFB) number, grant announcement number, the contract grant, or loan
award number, the application/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP-
DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal
amount of the award/loan commitment for the prime entity identified in Item 4 or 5.
10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity identified
in Item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services and include full address if different from IO(a). Enter
Last Name, First Name and Middle Initial (MI).
11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4) to the lobbying
entity (Item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all boxes that
apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.
12. Check the appropriate boxes. Check all boxes that apply. If payment is made through an in-kind contribution, specify
the nature and value of the in-kind payment.
13. Check the appropriate boxes. Check all boxes that apply. If other, specify nature.
14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to perform,
and the date( s) of any services rendered. Include all preparatory and related activity, not just time spent in actual contact
with Federal officials. Identify the Federal official(s) or employee(s) contacted or the officer(s), employee(s), or
Member(s) of Congress that were contacted.
15. Check whether or not a SF-LLL-A Continuation Sheet(s) is attached.
16. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
DocuSign Envelope ID: B7CC8492-1A0C-48C3-B890-562DC3D404A4
Consolidated Agreement FY21 Page 26 of27
1.
• • • • • •
4.
• •
Disclosure of Lobbying Activities
(Approved by 0MB 0348-0046)
C omplete this f orm to disclose lobbying activities pursuant to 31 U.S.C.1352
Type of Federal Action: 2. Status of Federal Action: 3. Report Type:
a. contract • a. Bid/offer/application • a. initial filing
b. grant • b. Initial Award • b. material change
C. cooperative agreement • C. Post-Award
d. loan For Material Change Only:
e. loan guarantee
f. loan insurance Year Quarter
Date of Last Report:
Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is Subawardee, Enter Name
Prime and Address of Prime:
Subawardee Tier , (if known)
Congressional District (if known) Congressional District (if known)
6. Federal Department/Agency: 7. Federal Program Name/Description:
CFDA Number (if applicable)
8. Federal Action Number (if known) 9. Award Amount (if known) :
$
10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if
(if individual, last name, first name, Ml): different from No. 10a.) (last name, first name, Ml):
(attach Continuation Sheet(s) SF-LLL-A, if necessary) (attach Continuation Sheet(s) SF-LLL-A, if necessary)
11. Amount of Payment (check all that apply): 13. Type of Payment (check all that apply):
$ actual planned • a. retainer • b. one-time fee
12. Form of Payment (check all that apply): • C. commission • d. contingent fee
• a. cash • e. deferred
• b. In-kind; specify: Nature • f. other; specify:
Value
14. Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or
Member(s) contacted, for Payment Indicated in Item 11 (attach Continuation Sheet(s) SF-LLL-A, if necessary):
15. Continuation Sheet(s) SF-LLL-A attached: •Yes •No
16. Information requested through this form is authorized by Signature: title 31 U. S. C. section 1352. This disclosure of lobbying
activities is a material representation of fact upon which
Print Name: reliance was placed by the tier above when this transaction
was made or entered into. This disclosure is required
pursuant to 31 U.S. C. 1352. This information will be Title:
reported to the Congress semi-annually and will be
available for public inspection. Any person who fails to file Telephone No: Date:
the required disclosure shall be subject to a civil penalty of
not less than $10,000 and not more than $100,000 for each
such failure.
1'1111101 11'1'1111
11
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·_; "'''"' ,,, ,L,>', I II '
... . ,i"i'spcill\;;, Standard Form -LLL II ~"""-·,·' .,,.,,::,,,,;;
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction
Proiect (0348-0046), Washington, D. C. 20503
DocuSign Envelope ID: B7CC8492-1A0C-48C3-B890-562DC3D404A4
Consolidated Agreement FY2 l Page 27 of27
ATTACHMENT D
STATE CERTIFICATIONS
Contractor Certifications Required by North Carolina Law
Instructions: The person who signs this document should read the text of the statutes and Executive Order listed below and consult with counsel and
other knowledgeable persons before signing. The text of each North Carolina General Statutes and of the Executive Order can be found online at:
• Article 2 of Chapter 64: http://www.ncga.state.nc.us/EnactedLegislation/StatuteslPDF /By Article/Chapter_ 64/ Article _2.pdf
• G.S. 133-32: http://www.ncga.state.nc.us/gascripts/statutes/statutelookup.pl?statute=133-32
• Executive Order No. 24 (Perdue, Gov., Oct. 1, 2009): http://www.ethicscommission.nc.gov/library/pdfs/Laws/E024.pdf
• G.S. 105-164.S(b): http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_105/GS_105-164.8.pdf
• G.S. 143-48.5: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter _ 143/GS _ 143-48.5 .html
• G.S. 143-59.1: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143/GS_143-59.l.pdf
• G.S. 143-59.2: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF /By Section/Chapter_ 143/GS _ 143-59.2.pdf
• G.S. 143-133.3: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_143/GS_143-l33.3.html
• G.S. 143B-139.6C: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143B/GS_143B-139.6C.pdf
Certifications
(1) Pursuant to G.S.133-32 and Executive Order No. 24
(Perdue, Gov., Oct. 1, 2009), the undersigned hereby
certifies that the Contractor named below is in
compliance with, and has not violated, the provisions of
either said statute or Executive Order.
(2) Pursuant to G.S. 143-48.5 and G.S. 143-133.3, the
undersigned hereby certifies that the Contractor named
below, and the Contractor's subcontractors, complies
with the requirements of Article 2 of Chapter 64 of the
NC General Statutes, including the requirement for each
employer with more than 25 employees in North
Carolina to verify the work authorization of its
employees through the federal E-Verify system." E-
Verify System Link: www.uscis.gov
(3) Pursuant to G.S. 143-59.l(b), the undersigned hereby
certifies that the Contractor named below is not an
"ineligible Contractor" as set forth in G.S. 143-59.l(a)
because:
(a) Neither the Contractor nor any of its affiliates has
refused to collect the use tax levied under Article 5
of Chapter 105 of the General Statutes on its sales
delivered to North Carolina when the sales met one
or more of the conditions ofG.S. 105-164.S(b); and
(b) [ check one of the following boxes]
D Neither the Contractor nor any of its affiliates
has incorporated or reincorporated in a ''tax
haven country" as set forth in G.S. 143-
59.l(c)(2) after December 31, 2001; or
• The Contractor or one of its affiliates has
incorporated or reincorporated in a "tax haven
Contractor's
Nrune:
Contractor's
Orange County Health Department
country" as set forth in G.S. 143-59.l(c)(2) after
December 31, 2001 but the United States is not
the principal market for the public trading of the
stock of the corporation incorporated in the tax
haven country.
(4) Pursuant to G.S. 143-59.2(b), the undersigned hereby
certifies that none of the Contractor's officers, directors,
or owners (if the Contractor is an unincorporated
business entity) has been convicted of any violation of
Chapter 78A of the General Statutes or the Securities Act
of 1933 or the Securities Exchange Act of 1934 within
10 years immediately prior to the date of the bid
solicitation.
(5) Pursuant to G.S.143B-139.6C, the undersigned hereby
certifies that the Contractor will not use a former
employee, as defined by G.S. 143B-139.6C(d)(2), of the
North Carolina Department of Health and Human
Services in the administration of a contract with the
Department in violation of G.S. 143B-139.6C and that a
violation of that statute shall void the Agreement.
( 6) The undersigned hereby certifies further that:
(a) He or she is a duly authorized representative of the
Contractor named below;
(b) He or she is authorized to make, and does hereby
make, the foregoing certifications on behalf of the
Contractor; and
( c) He or she understands that any person who
knowingly submits a false certification in response
to the requirements of G.S. 143-59. land -59.2 shall
be guilty of a Class I felony.
Authorized Agent: Signature _______________________ Date __________ _
Printed Name ---------------Title ________________ _
Witness: Signature _______________________ Date __________ _
Printed Name ----------------Title ________________ _
The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date this document immediately thereafter.
X
DocuSign Envelope ID: B7CC8492-1A0C-48C3-B890-562DC3D404A4
Orange County Health Director
4/21/2020
Quintana Stewart
4/21/2020
Kimberlee Quatrone Business Officer
II. Certification Regarding Drug-Free Workplace Requirements
2. The sites for the performance of work done in connection with the specific
agreement are listed below:
Street Address No. 3: 131 West Margaret Lane
Hillsborough, NC 27278
DocuSign Envelope ID: B7CC8492-1A0C-48C3-B890-562DC3D404A4