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ORANGE COUNTY-CONTRACT CONTROL SHEET <br /> Routing Order: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services, (5)Attorney,(6)Manager,(7)Clerk <br /> This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager <br /> determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for <br /> BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should <br /> be completed through the legal review process prior to being routed for signature. <br /> Department <br /> Party/Vendor Name: Person County Health Department Party/Vendor Contact Person: Dawn Coleman Contact Phone: 336-597-2204 <br /> Party/Vendor Address: 355 S Madison Blvd City Roxboro State:NC Zip:27573 Department: Public Health Amount: $8,000 Purpose: <br /> PCHD&OCHD will work to reach goals set forth in the CTG Project by supporting programs to promote policy, systems and <br /> evironmental change Budget Code(s):N/A Vendor#N/A (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No® <br /> Contract Type: (Check one)New® Renewal ❑ Amendment ❑ Effective Date October 1,2013 Approved by Board Yes❑No❑ <br /> Agenda Date: Title of Contract: Memorandum of Understanding <br /> If this is a Grant Agreement, pre-application has been approved by the Board of Commissioners Yes❑No❑. If submitted for bid were <br /> bids/RFPs received Yes❑No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to <br /> technical content: <br /> Department Director's Signature: Date: 0 <br /> (Applicable on y ses or related services)This contract has been reviewed and approved by the Information <br /> Technology Director as to technical content and information tec cifications: <br /> ate: <br /> Risk Management <br /> Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance Required ❑. Hold <br /> Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,this contract is approved <br /> by the Risk Manager: J j G4 <br /> Risk Manager's Signature: ��_��..�� Date: <br /> lO�Z9 <br /> Financial Services <br /> This Contract is conditioned on appropriation by the Board of Commissioners Yes❑No[9.1/ A budget amendment is necessary <br /> before approval Yes❑ NoIf budget amendment is necessary, please attach to this form. This instrument has been pre-audited in the <br /> manner required by the Local Government Budget and Fiscal Controlict: <br /> Financial Services Director's Signature: va"4� A V� D 10 36, 13 <br /> L ate: <br /> County Attorney <br /> Approval by Board ❑ (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC <br /> consultant contract). Approval by Manager..E(Most other contracts$1,000 and above). Department Director approval only❑ (Under <br /> $1,000). This contract has be n/iewed and moved by the Attorney as to legal form and sufficiency: <br /> Attorney's Signature ---- -_ Date: <br /> County Manager <br /> This contract has been reviewed and is ap rov by the County Manager Yes Io❑. <br /> This contract has been reviewe is si ture b t e C 'r Yes❑No❑. <br /> Manager's Signature: Date: <br /> Clerk to the Board <br /> Approved by BOCC on the_day of ,20 . Submitted for Chair signature on the_day of ,20 <br /> Clerk's Signature: Date: <br /> Revised March 2012 <br />