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N.C. Department of Environment, Health and Natural Resources Page 1 of 5
<br /> Division of General Services FY 1995-96
<br /> CONTRACT ADDENDUM
<br /> Women's Preventive Health Branch 96 51510 068
<br /> Office, Section, or Branch Contract Number
<br /> Orange Family Planning
<br /> Contractor Activity
<br /> Suggested order of completion of data items: La., Lb., I.c., 1., 2., 3., and 4.
<br /> 1. 1300 Total persons will be served (sum of 1.a., 1.b., and 1.c.). HSIS
<br /> Report, HBS 085, Pat. Char., Row "P, " "Total" column.
<br /> a. 380 Persons will be served, aged 19 or less. HSIS Report, HBS
<br /> 085, Pat. Char. Report, Row "P, " third through fifth
<br /> columns.
<br /> b. 660 Persons will be served, at or below 150% of poverty,
<br /> aged 20-44. HSIS Report, HBS 085, Pat. Char. Report,
<br /> Rows "H.1. and H.2., " sum of sixth through tenth
<br /> columns.
<br /> C. 260 Other persons will be served. HSIS Report, HBS 085,
<br /> Row "H.3., " sum of sixth through tenth columns.
<br /> 2. 13 % Percent of persons aged 19 or less will be served. (See attached need
<br /> table for figure to use as denominator, item 1.a., as numerator). HSIS
<br /> Report HBS 084, Evaluation Report, Item "I.A. "
<br /> 3. 12 % Percent of persons at or below 150% of poverty, aged 20-44, will be
<br /> served. (See attached need table for figure to use as denominator, item
<br /> 1.b., as numerator). HSIS Report HBS 084, Evaluation Report, Item
<br /> "I.B. "
<br /> 4, 80 Percent of caseload from target population (item 1.a. + item 1.b.,
<br /> divided by item 1). HSIS Report, HBS 084, Evaluation Report,
<br /> Item "XI. "
<br /> 5. The local health agency has written policies in place for family planning services:
<br /> a. Description of local family planning services, including local protocols,
<br /> standing orders and components of Initial, Complete, Limited and Extended
<br /> Revisits.
<br /> Reviewed by
<br /> DEHNR 3300 (Revised 2/95) "'L'57 3 J--
<br /> General Services Division (Review 9/95) Initials Date
<br />
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