Orange County NC Website
Browse       Search
DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) <br />Program Name: Duke HomeCare & Hospice <br />Program Primary Contact and Title: William Holloman, Hospice Bereavement & Family Services <br />Telephone Number: 919.618.8954 E -Mail: VVilliam.holloman@duke.edu <br />a) Indicate the type of Human Service Needs Priority, if program applicable: <br />❑ Priority Area #1: Healthcare 1 Safety <br />❑ Priority Area #2 <br />❑ Priority Area #3: <br />b) Indicate the type of program for which you are requesting funding <br />(Check all that apply to this program) <br />Program Category <br />Youth <br />Adult <br />Elderly <br />Disabled <br />Public Housing <br />Neighborhoods /Residents <br />Affordable Housing <br />Affordable Healthcare <br />Education <br />x <br />x <br />X <br />Family Resources <br />Jobs /Jobs Training <br />x <br />x <br />x <br />Food <br />Transportation <br />Other: Please specify <br />grief counseling <br />x <br />x <br />x <br />c) Provide a bulleted list of other agencies, if any, with which your agency <br />coordinates /collaborates to accomplish or enhance the Projected Results in the Program(s) to <br />be funded. For each, briefly describe the coordinated /collaborative efforts. <br />Program Description (3 pages OR LESS) <br />Please provide the following information about the proposed program: <br />d) Summarize the program services proposed and how the program will address a Town /County <br />priority /goal? <br />e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human <br />Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel <br />Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council /Board <br />Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services <br />Needs Assessment) to support the need for this program. <br />DO NOT SUBMIT THIS PAGE 1/19/2018 3:41:03 PM Page 7 of <br />