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t - ST) <br /> 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: UNC Department of Family Medicine Party/Vendor Contact Person: Pam Hoover Contact Phone: 919-966-3907 <br /> Party/Vendor Address:UNC-CH,CB 7595 City Chapel Hill State:NC Zip:27599-7595 Department:Family Medicine Amount: <br /> $25,000 Purpose:Provide Health Screening and Health Coaching for Orange County Employees Budget Code(s): 10295020/720022 <br /> Vendor#21243 (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No® Contract Type: (Check one)New® Renewal <br /> ❑ Amendment ❑ Effective Date 6/1/2014 Approved by Board Yes❑No® Agenda Date: Title of Contract:Agreement <br /> Between Orange County and The University of North Carolina at Chapel Hill for its Department of Family Medicine in the School of <br /> Medicine <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: dPi1C6{� � � Date: l j H <br /> IT Director <br /> (Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the Information <br /> Technology Director as to technical content and information technology specifications: <br /> IT Director's Signature: 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 sh <br /> by the Risk Manager: D J lJ <br /> Risk Manager's Signature:_ �� Date: NOV 2 4 2'�14 <br /> u1� <br /> Financial Services By <br /> This Contract is conditioned on appropriation by the Board of Commissioners Yes❑No[/ A b <br /> before approval Yes❑ No[5If 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 Act: <br /> Financial Services Director's Signature: �� Date: 1 r 7 <br /> if laq <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 b Manager N(Most other contracts$1,000 and above). Department Director approval only❑ (Under <br /> $1,000). This contract has been eviewed and approved by the Attorney as to legal form and sufficiency: <br /> Attorney's Signature Date: <br /> 7 County Manager <br /> This contract has been reviewed and is approved by the County Manager No <br /> Yes ❑. <br /> This contract has been reviewed and is for signature by the Chair Yes❑No❑. <br /> /Manager's Signature: Date: <br /> to <br /> Cler the Board <br /> Approved by BOCC on the_day of ,20 . Submitted for Chair signature on the day of '120 <br /> Clerk's Signature: Date: <br /> Revised March 2012 <br />