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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 shalf 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: Piedmont Health Services Party/Vendor Contact Person: Brian Toomey Contact Phone: 781-687-9500 <br /> Party/Vendor Address:229 Lloyd Street City Carrboro State:NC Zip:27510 Department:Public Health Amount: 10,000 Purpose: <br /> Provider shall be responsible for means,methods,techniques,sequence,safety program and procedures necessM to properly and fully <br /> complete the work set forth in the Scope of Services Budget Code(s): 10414020-630000 Vendor#27898 (N/A if new vendor) <br /> Vendor is a BOCC consultant? Yes❑No® Contract Type: (Check one)New❑ Renewal® Amendment ❑ Effective Date July 1, <br /> 2014 Approved by Board Yes❑No❑ Agenda Date: Title of Contract: Outside Agency Performance Agreement <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❑Non 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: <br /> (Applicable only to hardwar ftPul e Ptff' lated services)This contract has been reviewed and approve ire fir xyttmiO4--- <br /> Technology Director as to technical content and information tec s ecifications: <br /> irec ors i na ure: Date: <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 show � i"lJ sa i8 aTr� <br /> by the Risk Manager: n n L� <br /> �� -��- AUG 2 0 2014 <br /> Risk Manager's Signature: Date: <br /> ,� <br /> Financial Services By <br /> This Contract is conditioned on appropriation by the Board of Commissioners Yes❑No[� A budget amendment is necessary <br /> before approval Yes❑No.If 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 Control A <br /> Financial Services Director's Signature: , Date: (0 /� <br /> 10114 <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 anager A(Most other contracts$1,000 and above). Department Director approval only❑ (Under <br /> $1,000). This contract has been r wed and approved 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 approved by the County Manager Yes o❑. <br /> This contract has been reviewed and is signature by e Chair Yes o❑. l <br /> Manager's Signature: _ Date: <br /> Cler 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 />