2012-392 S EMS - UNC Emergency Medical Director

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ORANGE COUNTY—CONTRACT CONTROL SHEET .kouting Order: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager .xtermines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should be completed through the legal review process prior to being routed for signature. Department Party/Vendor Name: The University of North Carolina at Chapel Hill Party/Vendor Contact Person: Brenda Cooper Contact Phone: Party/Vendor Address: CB#7594 170 Manning Drive,Physicians Office Bldg. City Chapel Hill State:NC Zip:27514 Department:Emergency Medicine Amount: 47,000 Purpose: Provision of Medical Direction Budget Code(s): 10757520 630000 Vendor#N/A (N/A if new vendor) Vendor is a BOCC consultant? Yes❑NoEl Contract Type:(Check one)New❑ Renewal N Amendment ❑ Effective Date July 1,2012 Approved by Board Yes❑No❑ Agenda Date: Title of Contract:An Agreement to provide emergency medical director services If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No❑. If submitted for bid were bids/RFPs received Yes❑No❑ Bid/RFP number This ontract has been reviewed and approved by the Department Director as to technical content: Department Director's Signature: Date: 0 IT Director (Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the Information Technology Director as to technical content and information technology specifications: IT Director's Signature: Date: Risk Management Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; ❑ OR No Insurance Required ly Hold Contract pending receipt of Certificate of Insurance With incorporation of Insurance provisions as shown, this contract is approved by the Risk Manager: Risk Manager's Signature: Date: Financial Services This Contract is conditioned tOon appropriation by the Board of Commissioners Yes❑NoFr A budget amendment is necessary before approval Yes❑NoEX If budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the manner required by the Local Government Budget nd Fiscal Contr Act: Financial Services Director's Signature: Allt� _�. ' � Date: County Attorney Approval by Board ❑ (Contracts over $90,000.00 for goods or services, $250,000.00 for construction, or any BOCC consultant contract). Approval by Mana (All other contracts). This contract has been reviewed and approved by the Attorney as to legal form and sufficiency: Attorney's Signature Date: County Manager I This contract has been reviewed and is approved by the County,,Wnager Yes N o❑. .0- This contract has been reviewed and is to be submitted for BO co * eration Yes❑No2.' Manager's Signature: Date: Cl/erk to the Board Approved by BOCC on the day of 20 Submitted for Chair signature on the day of 20 Clerk's Signature: Date: Revised April 2010 0 1