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Home My WebLink About2021-523-E-Health-Planned Parenthood South Atlantic-Outside Agency Agreement Orange County Outside Agency Performance Agreement ARPA Funds Revised 9/2021 Page 1 of 13 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2021, (“Effective Date”) by and between the County of Orange, a political subdivision of the State of North Carolina, Post Office Box 8181, Hillsborough, North Carolina, 27278, ("County") and Planned Parenthood South Atlantic, a not-for-profit corporation, located at 1765 Dobbins Drive, Chapel Hill, North Carolina 27514 (“Provider”). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners. NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and «Agencys_Name» agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2021 to June 30, 2022. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit “A” and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of $20,000. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $5,000. The first payment is contingent upon receipt of the agency’s performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County’s obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Orange County Outside Agency Performance Agreement Page 2 of 13 Rev.9/21 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 – December 31; January 1 – March 31 and April 1 - June 30. Reports are due on January 10, April 10, and July 10 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services, upon reasonable notice during normal working hours. 5. Termination. a. Termination for Cause. In the event of any of the circumstances set forth below (hereinafter referred to as “default”), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten (10) business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County’s remedies in law or in equity. DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Orange County Outside Agency Performance Agreement Page 3 of 13 Rev.9/21 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. e. Waiver. The payment of any sums by the County under this Agreement or the failure of the County to require compliance by the Provider with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. 6. Responsibilities of the County. Cooperation and Coordination. The County has designated (Quintana Stewart) to act as the County's representative with respect to the Project who shall have the authority to render decisions within guidelines established by the County Manager or the County Board of Commissioners and who shall be available during working hours as often as may be reasonably required to render decisions and to furnish information. 7. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker’s Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury, bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. v. Sexual Misconduct. Sexual Abuse/Molestation Insurance is required when Provider works directly one-on-one with children, elderly or other at-risk populations. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A - Statutory State DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Orange County Outside Agency Performance Agreement Page 4 of 13 Rev.9/21 NC & Coverage B - Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate • Sexual Misconduct $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability) required under this Agreement shall name the County as an additional insured party and as a certificate holder. For more information see the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements, (each document is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php.) Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough, NC 27278 d. Nothing in this section is intended to affect or abrogate the County’s sovereign immunity defenses. 8. General Provisions. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. b. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Non-discrimination Policy, which is incorporated herein by reference and can be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php. The County may enforce this provision by an action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Orange County Outside Agency Performance Agreement Page 5 of 13 Rev.9/21 c. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. d. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The Orange County Living Wage Policy, which is incorporated herein by reference, can be viewed at: http://www.orangecountync.gov/departments/purchasing_division/contracts.php. The County’s living wage is $ 15.40 per hour. To the extent possible, Orange County recommends that Provider provide a living wage to its employees. e. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. f. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. g. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. h. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. i. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County’s sovereign immunity defenses. j. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. k. Compliance With The Contract Work Hours And Safety Standard Act. (See 29 C.F.R. §5.5) i. Overtime requirements. No Provider or sub-Provider contracting for any part of the contract work which may require or involve the employment of laborers or mechanics shall require or permit any such laborer or mechanic DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Orange County Outside Agency Performance Agreement Page 6 of 13 Rev.9/21 in any workweek in which he or she is employed on such work to work in excess of forty hours in such workweek unless such laborer or mechanic receives compensation at a rate not less than one and one-half times the basic rate of pay for all hours worked in excess of forty hours in such workweek. ii. Violation; liability for unpaid wages; liquidated damages. In the event of any violation of the clause set forth in paragraph (b)(1) of 29 C.F.R.§5.5 the Provider and any sub-Provider responsible therefor shall be liable for the unpaid wages. In addition, such Provider and sub-Provider shall be liable to the United States (in the case of work done under contract for the District of Columbia or a territory, to such District or to such territory), for liquidated damages. Such liquidated damages shall be computed with respect to each individual laborer or mechanic, including watchmen and guards, employed in violation of the clause set forth in paragraph (b)(1) of 29 C.F.R. §5.5, in the sum of $26 for each calendar day on which such individual was required or permitted to work in excess of the standard workweek of forty hours without payment of the overtime wages required by the clause set forth in paragraph (b)(1) of 29 C.F.R. §5.5. iii. Withholding for unpaid wages and liquidated damages. The (write in the name of the Federal agency or the loan or grant recipient) shall upon its own action or upon written request of an authorized representative of the Department of Labor withhold or cause to be withheld, from any moneys payable on account of work performed by the Provider or sub-Provider under any such contract or any other Federal contract with the same prime Provider, or any other federally- assisted contract subject to the Contract Work Hours and Safety Standards Act, which is held by the same prime Provider, such sums as may be determined to be necessary to satisfy any liabilities of such Provider or sub-Provider for unpaid wages and liquidated damages as provided in the clause set forth in paragraph (b)(2) of 29 C.F.R. §5.5. iv. Subcontracts. The Provider or sub-Provider shall insert in any subcontracts the clauses set forth in paragraph (b)(1) through (4) of 29 C.F.R. §5.5 and also a clause requiring the sub-Providers to include these clauses in any lower tier subcontracts. The prime Provider shall be responsible for compliance by any sub-Provider or lower tier sub-Provider with the clauses set forth in paragraphs (b)(1) through (4) of 29 C.F.R. §5.5. l. Byrd Anti-Lobbying Amendment, 31 U.S.C. § 1352 (as amended). Providers who apply or bid for an award of $100,000 or more shall file the required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, officer or employee of Congress, or an employee of a Member of Congress in connection with obtaining any Federal contract, grant, or any other award covered by 31 U.S.C. § 1352. Each tier shall also disclose any lobbying with non-Federal funds that takes place in connection with obtaining any Federal DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Orange County Outside Agency Performance Agreement Page 7 of 13 Rev.9/21 award. Such disclosures are forwarded from tier to tier up to the recipient who in turn will forward the certification(s) to the awarding agency. m. Clean Air And Federal Water Pollution Control Act (Applicable only if the contract is more than $150,000) i. Clean Air Act. (a) The Provider agrees to comply with all applicable standards, orders, or regulation issue pursuant to the Federal Water Pollution Control Act, as amended, 33 U.S.C. 1251 et seq. (b) The Provider agrees to include these requirements in each subcontract exceeding $150,000 financed in whole or in part with Federal assistance provided by FEMA. ii. Federal Water Pollution Control Act. (a) The Provider agrees to comply with all applicable standards, orders or regulations issued pursuant to the Clean Air Act, as amended, 42 U.S.C. § 7401 et seq. (b) The Provider agrees to report each violation to the (Health Director, Quintana Stewart) and understands and agrees that the (Health Director) will, in turn, report each violation as required to assure notification to the Federal Emergency Management Agency, and the appropriate Environmental Protection Agency Regional Office. (c) The Provider agrees to include these requirements in each subcontract exceeding $150,000 financed in whole or in part with Federal assistance provided by FEMA. n. Suspension And Debarment i. This Agreement is a covered transaction for purposes of 2 C.F.R. pt. 180 and 2 C.F.R. pt. 3000. As such, the Provider is required to verify that none of the Provider’s principals (defined at 2 C.F.R. § 180.995) or its affiliates (defined at 2 C.F.R. § 180.905) are excluded (defined at 2 C.F.R. § 180.940) or disqualified (defined at 2 C.F.R. § 180.935). ii. The Provider must comply with 2 C.F.R. pt. 180, subpart C and 2 C.F.R. pt. 3000, subpart C, and must include a requirement to comply with these regulations in any lower tier covered transaction it enters into. iii. This certification is a material representation of fact relied upon by Orange County. If it is later determined that the Provider did not comply with 2 C.F.R. pt. 180, subpart C and 2 C.F.R. pt. 3000, subpart C, in addition to remedies available to Orange County, the Federal Government may pursue available remedies, including but not limited to suspension and/or debarment. DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Orange County Outside Agency Performance Agreement Page 8 of 13 Rev.9/21 iv. The bidder or proposer agrees to comply with the requirements of 2 C.F.R. pt. 180, subpart C and 2 C.F.R. pt. 3000, subpart C while this offer is valid and throughout the period of any contract that may arise from this offer. The bidder or proposer further agrees to include a provision requiring such compliance in its lower tier. o. Access to Records. The following access to records requirements apply to this contract: i. The Provider agrees to provide State of North Carolina, the County, the FEMA Administrator, the Comptroller General of the United States, or any of their authorized representative access to any books, documents, papers, and records of the Contractor, which are directly pertinent to this contract for the purposes of making audits, examinations, excerpts, and transcriptions. ii. The Provider agrees to permit any of the foregoing parties to reproduce by any means whatsoever or to copy excerpts and transcriptions as reasonably needed. iii. The Provider agrees to provide the FEMA Administrator or his authorized representative access to construction or other work sites pertaining to the work being completed under the contract. iv. In compliance with the Disaster Recovery Act of 2018, the County and Provider acknowledge and agree that no language in this contract is intended to prohibit audits or internal reviews by the FEMA Administrator or the Comptroller General of the United States. p. DHS Seal, Logo, and Flags. The Provider shall not use the DHS seal(s), logos, crests, or reproductions of flags or likenesses of DHS agency officials without specific FEMA pre-approval. q. Compliance with Federal Law, Regulations and Executive Orders. This is an acknowledgement that FEMA financial assistance will be used to fund all or a portion of the Agreement. The Provider will comply with all applicable Federal law, regulations, executive orders, FEMA policies, procedures, and directives.” r. No Obligation by Federal Government. The Federal Government is not a party to this Agreement and is not subject to any obligations or liabilities to the non- Federal entity, Provider, or any other party pertaining to any matter resulting from this Agreement. s. Program Fraud and False or Fraudulent Statements or Related Acts. The Provider acknowledges that 31 U.S.C. Chap. 38 (Administrative Remedies for False Claims and Statements) applies to the Provider’s actions pertaining to this Agreement. DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Orange County Outside Agency Performance Agreement Page 9 of 13 Rev.9/21 t. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. u. Entire Agreement. This Agreement represents the entire and integrated agreement between the County and the Provider and supersedes all prior negotiations, representations or agreements, either written or oral. This Agreement may be amended only by written instrument signed by both parties. Modifications may be evidenced by facsimile signatures. v. Notices. Any notice required by this Agreement shall be in writing and delivered by certified or registered mail, return receipt requested to the following: Orange County Provider’s Name Planned Parenthood So. Atlantic Attention: Kimberlee Quatrone Attention: Jenny Black P.O. Box 8181 Address: 100 S. Boylan Ave. Hillsborough, NC 27278 Raleigh, NC 27603 Email:kquatrone@orangecountync.gov Email: jenny.black@ppsat.org w. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and on behalf of the Provider _____________________________ _______________________ Jenny Black, President and CEO Date For and on behalf of Orange County Government _______________________________ ________________________ Bonnie Hammersley, County Manager Date DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA 9/23/2021 9/23/2021 Orange County Outside Agency Performance Agreement Page 10 of 13 Rev.9/21 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: Planned Parenthood South Atlantic Party/Vendor Contact Person: Jenny Black Contact Phone: 919-833-7526 x6140 Party/Vendor Address: 1765 Dobbins Dr. City Chapel Hill State: NC Zip: 27514 Department: Health Amount: $20,000 Purpose: Outside Agency Agreement Budget Code(s): 49495050-710013-96002 Vendor # 800040 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 7-1-2021 Approved by Board Yes No Agenda Date: June 15, 2021 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: Department Director’s Signature ________________________________________ Date: ________ 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: Waiting on new template with ARPA language. 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 sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@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:_________ DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA 9/23/2021 9/23/2021 9/23/2021 9/23/2021 COVER PAGE Applicant Contact Information Applicant Organization's Legal Name: Planned Parenthood South Atlantic Applicant Organization's Physical Address: 1765 Dobbins Dr, Chapel Hill, NC 27514 Applicant Organization's Mailing Address: 100 S Boylan Ave, Raleigh, NC 27603 Applicant Organization's Web Address: ppsat.org Executive Director: Jenny Black Telephone Number: 919-833-7526 X6140 E-Mail: jenny.black@ppsat.org Tax ID Number: Funding Request Please list all Fiscal Year 2022 Human Services {HS) funding requested for all programs and the proposed use of funds (please list program name only) Program Carrboro Chapel Orange Total HS Hill -HS Coun�-HS Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Operations or Personnel Operations Personnel Operations Sexual health education and outreach $1,000 $5,000 $20,000 $26,000 Personnel Personnel Personnel Personnel Totals $1,000 $5,000 $20,000 $26,000 Briefly explain your proposed use of funds: PPSAT requests $26,000 from the collective Human Services funding opportunities to support the personnel costs for one full-time community health educator in Orange County. To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: --��--�0 __ � _________ _ Executive Director Signature: K� JV\ -,Mr.Fl� Board Chairperson Cover Page 12/17/2020 Date I l.../ 1"1 / ·2-01--0 Date Page 6 of 20 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Program information P a g e 8 o f 20 AGENCY INFORMATION Please provide the following information about your agency: 1.Date of Incorporation (Month/Year): July 1980 2.Agency’s Purpose/Mission (no more than a few sentences): The mission of Planned Parenthood South Atlantic (PPSAT) is to provide comprehensive reproductive and sexual health care services in settings that preserve and protect the individual’s right to privacy and informed decisions; provide educational programming that fosters a culture of healthy sexuality; and advocate public policies that advance these rights and expand access to these services. 3.Please provide a brief description of your organization’s past achievements in carrying out similar projects and evidence of successful record of meeting proposed budgets and timetables (no more than 100 words). For 40 years, PPSAT has provided high-quality education that reflects the needs of young people, their families, patients, and local communities. Last year, PPSAT provided sex education to more than 18,000 young people in settings such as public schools, youth-serving organizations, and health departments. The education team emphasizes multi-session sex education programs that are evidence-based and proven to meet the needs of the participants. PPSAT has offered education programs in Orange County for the past 38 years. 4.Living Wage: Does this agency pay permanent employees a minimum living wage? (Yes / No) If yes, is this agency an Orange County Living Wage Certified Employer? Yes If no, please briefly explain. Schedule of Positions: # of FTE – Full-Time Paid Positions: 198 # of FTE – Part-Time Paid Positions: 96 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program . 5.Program Name: Sexual Health Education and Outreach Program Primary Contact and Title: Heather Williams, Community Health Educator Telephone Number: (910)729-0971 Email: heather.williams@ppsat.org 6.Please briefly describe the proposed program, including an explanation of how it aligns with the Town of Chapel Hill and Carrboro’s Results Framework, and Orange County BOCC Goals and Priorities, and the target population to benefit from the program. (100 words or less) PPSAT will provide Orange County teens and young adults with comprehensive sexuality education that promotes healthy behavior and responsible choices to reduce unintended pregnancy and sexually transmitted infections (STIs) rates. This program will contribute to a network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all OC residents, and will help youth develop age-appropriate skills and demonstrate new healthy lifestyle behaviors around sexual health (CH/ Carr - Obj. 3, Intermediate Results 3.2). The program will ensure a high quality of life for teens and encourage them to be lifelong learners (OC BOCC, Goal 6). EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Program information P a g e 9 o f 20 7.Target Population: Please complete the table below with numbers (not percentages) of individuals served and projected to be served. Program Target Population Demographics Projected 2019-2020 Actual 2019-20 Projected 2020-21 Projected 2021-22 Gender Men Women Nonbinary/Genderqueer Self-Describe Total 365 547 380 380 Race and Ethnicity Black or African-American American Indian or Alaska Native Asian White Native Hawaiian or other Pacific Islander Two or more races Some other race Total 365 547 380 380 Of the above, how many Hispanic/Latin o Of the above, how many non-Hispanic/Latino Total 365 547 380 380 Age 0-5 years 6-18 years 19-50 years 51+ years Total 365 547 380 380 Geographic Location Town of Chapel Hill Town of Carrboro Orange County ( Outside of Chapel Hill/Carrboro) Outside of Orange County Total 365 547 380 380 Income Low-income (80% of the Area Median Income and Below) Please see income table in the attachments Total **** 90 260 15 219 327 1 100 260 20 100 260 20 20 20 15 10 300 12 4 44 487 50 30 270 10 20 50 30 270 10 20 50 315 54 493 50 330 50 330 0 180 180 5 0 386 161 0 0 300 70 10 0 300 70 10 300 25 40 381 136 28 220 70 90 220 70 90 **** *PPSAT does not collect income information for program participants. 2 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Program information P a g e 10 o f 20 8. Cost Per Individual This cost per individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2019-20 Projected 2020-21 Projected 2021-22 Total Cost of Program Total # of Individuals Cost Per Individual 9.Performance Indicators For Chapel Hill and Carrboro applicants: Please complete the following chart with information about the Strategic Objective, Intermediate Result, and the Agency Performance Indicator for each program for which you are applying for funding . Please see the Results Framework in the Attachments section as a reference. Program Name: Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes Residents Increase their livelihood security Residents improve their health outcomes Intermediate Result (please choose one from the Results Framework) Insert Intermediate Result here. Actual 2019-20 Projected 2020-21 Projected 2021-22 Performance Indicators (Please choose at least one performance indicator to report on from the Results Framework, and add additional performance indicators that you would like to report to the Towns. Please insert additional rows as needed, listing one per row). 533 380 380 $49,093 x 3.2 Residents demonstrate new healthy lifestyle behaviors. % and # of program participants who demonstrate new life skills: Number of adolescents who participate in multi-session, evidence-based curricula. Average increase in knowledge about pregnancy and STI prevention. 32 27% 30 25% 30 25% Number of students reached by peer educators Number of parents reached through parent workshops Percentage of parents who report an increased comfort in talking about sexuality with their children Number of participants reached by single- session programs Percentage of individuals who report an increased understanding of their risk of pregnancy or STI transmission 480 300 300 6 15 15 100%75%75% 14 35 35 93%75%75% $44,917 $50,314 $84.27 $129.19 $132.41 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Outside Agencies/Human Services Program information P a g e 11 o f 20 Please use the drop down menu below to select which function area best aligns with your agency and program(s) in which you are requesting funding. Please select only one from the drop-down menu below. Public health and health education If you selected other, please tell us what function area best aligns with your organization: Please indicate three program goals/performance measures below. A few notes: •If you use percentages, please put the actual number equivalence. •Please ensure your performance measures are outcome based and not outputs. Program Goal # 1 Performance Measure (How will you accomplish your goal?) Actual Results (Outcome) Ending FY19-20 Projected Results (Outcome) Ending FY2021 Projected Results (Outcome) Ending FY2022 Program Goal # 2 Performance Measure (How will you accomplish your goal?) Actual Results (Outcome) Ending FY19-20 Projected Results (Outcome) Ending FY2021 _________________ Number of adolescents who participate in multi-session, evidence-based curricula; average increase in knowledge about pregnancy and STI prevention. Adolescents will engage with the program and learn new life skills. 32; 47% 30; 25% 30; 25% Parents will have the skills and information they need to talk to their children about sexuality. Number of parents reached through parent workshops; percentage of parents who report an increased comfort in talking about sexuality with their children 6; 100% 15; 75% EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Outside Agencies/Human Services Program information P a g e 12 o f 20 Projected Results (Outcome) Ending FY2022 Program Goal # 3 Performance Measure (How will you accomplish your goal?) Actual Results (Outcome) Ending FY19-20 Projected Results (Outcome) Ending FY2021 Projected Results (Outcome) Ending FY2022 15; 75% The educator will engage with community members and educate them on their sexual health. Number of participants reached by single-session programs; percentage of individuals who report an increased understanding of their risk of pregnancy or STI transmission. 14; 93% 35; 75% 35; 75% EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Attachments P a g e 14 o f 20 4. ATTACHMENTS Description of Required Attachments a)Financial Audit A recent financial audit that should cover CY2019, for calendar year agencies, and FY2019-20, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a certified audit/report should not complete the form. Schedule of Receipts and Expenditures form is listed on the Town’s and county website here. b)Agency Budget Please complete the provided template or submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template. Please explain other in your budget). Agency Budget Template is listed on the Town’s and County website here. Please submit In PDF form only. c)Program Budget You may complete the provided template, or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template. Please explain other in your budget). Program Budget Template is listed on the Town’s and County website here. Please submit in pdf only. d)IRS Federal Form 990 A copy of the agency’s 2019 Form 990 is required. The specific form depends upon the agency’s financial activity. Review the IRS’ table guide, for more details. For Form 990-N (e-postcard) filers, include a copy of the postcard, with the agency’s application materials. e)NC Solicitation License A copy of the agency’s current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State’s licensing website and its Frequently Asked Questions Guide (PDF), about exemptions. If exempt per N.C.G.S. § 131F-3, include a copy of the exemption letter with the agency’s application materials. f)IRS Federal Tax-Exemption Letter A copy of the agency’s current IRS tax-exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS’ Customer Account Services. g)List of Board of Directors Provide the following information about each board of director’s member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Attachments P a g e 15 o f 20 h)Solid Waste Program Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency’s FY 2019-20 Solid Waste Program Fee, OR b.) a statement on agency letter head indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. i)Certificate of Liability Insurance A copy of the agency’s current certificate, from the agency’s insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker’s Compensation compliance, include a statement explaining why, with the agency’s application materials. NOTE: Proof of insurance is not required at the time of application submission. If your agency is approved for funding, documentation of insurance must be provided to the jurisdiction awarding the funding when the contract is awarded. The insurance certificate should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 – June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. NOTE: Upon request, insurance requirements may be reviewed on a case by case basis by the Town or County. Please contact the staff identified on the Submission Requirements on Page 2 if you have questions or would like to request a review of your insurance requirements. Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Compensation1 Limits for Coverage A - Statutory State NC, for each employee Limits for Coverage B - Employers Liability of: $1 million Each Occurrence $1,000,000 BID2 limit Limits for Coverage A - Statutory State NC, for each employee Limits for Coverage B - Employers Liability of: $100,000 Each Occurrence $100,000 BID for each employee $500,000 BID limit Limits for Coverage A - Statutory State NC, for each employee Limits for Coverage B - Employers Liability of: $500,000 each accident, $500,000 BID for each employee $500,000 for BID limit Commercial General Liability $100,000 Property Damage Liability $1 Million Bodily Injury and Property Damage Limit $1 million Each Occurrence $2 million Aggregate $1 million Each Occurrence $2 million Aggregate Automobile Liability Not Applicable $1 million Each Occurrence *Only required for agencies doing travel as part of the agreement with the Town. $1 million Each Occurrence Professional Liability Not Applicable $1 million Each Occurrence $2 million Aggregate $1 million Each Occurrence $2 million Aggregate Sexual Abuse & Molestation Not Applicable $1 million Each Occurrence $2 million Aggregate $1 million Each Occurrence $2 million Aggregate EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Attachments P a g e 16 o f 20 *Only required for agencies doing direct work with minors (under the age of 18). Cyber Liability Not Applicable $1 million Each Occurrence $2 million Aggregate *Only required for agencies transmitting personal identifiable information that is disseminated electronically. $1 million Each Occurrence $2 million Aggregate Visit the NC Industrial Commission’s website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen’s compensation insurance. Bodily Injury by Disease (BID). Please visit Orange County’s Risk Management page for more information about the County’s Minimum Insurance Requirements. For additional information regarding the Town of Chapel Hill’s Minimum Insurance Requirements, please contact the Office of Risk Management or Business Management. Town of Chapel Hill At-your-Service. 2020 Income Limits US Department of Housing and Urban Development (HUD) Durham-Chapel Hill Metropolitan Statistical Area (Durham, Orange, and Chatham Counties) Income Level 1 person 2 people 3 people 4 people 5 people 6 people 7 people 8 people 30% area median income $19,100 $21,800 $24,550 $27,250 $30,680 $35,160 $39,640 $44,120 50% area median income $31,850 $36,400 $40,950 $45,450 $49,100 $52,750 $56,400 $60,000 60% area median income $38,200 $43,680 $49,140 $54,540 $58,920 $63,300 $67,680 $72,200 80% area median income $50,900 $58,200 $65,450 $72,700 $78,550 $84,350 $90,150 $96,000 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) EXHIBIT “B” Scope of Services – FY 2021-2022 Outside Agency Performance Agreement Agency Name: Planned Parenthood South Atlantic Program Name: Sexual Health Education and Outreach Funding Award: $20,000 Outline how the agency will spend Orange County’s funding award. Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2022. • PPSAT's educator will provide Orange County teens and young adults with medically accurate, intensive, and balanced sexuality education programs. • PPSAT's educator will engage Orange County parents and caregivers in programs that help families talk more comfortably about issues that can be difficult to discuss. • PPSAT's educator will provide science-based community presentations in Orange County designed for the age and demographics of the audience. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure’s description or for an earlier performance measure. Performance Measures Anticipated Results Number of adolescents who participate in multi-session, evidence-based curricula; average increase in knowledge about pregnancy and STI prevention. 30; 25% Number of parents reached through parent workshops; percentage of parents who report an increased comfort in talking about sexuality with their children. 15; 75% Number of participants reached through single-session programs; percentage of indiviuals who report an incrased understanding of their rick of pregnancy of STI transmission. 35; 75% Number of students reached through peer educators with reproductive health care information 300 Expense Description Amount Salary and Benefits - Community Health Educator $20,000 DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA 9/23/2021President and CEO Orange County Outside Agency Performance Agreement Page 13 of 13 Rev.9/21 ATTACHMENT “A” Orange County Certifications – FY 2021-22 Outside Agency Performance Agreement Chief Contact, Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title, residential address; phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing, with the name, physical address, mailing address and if possible, phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not, please explain on a separate sheet of paper. Alignment with Organization’s Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. Certified by: _______________________ Title: __________________________ Date: ___________ (Provider’s Signature) DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA 9/23/2021President and CEO DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA