R 2014-579 Health - UNC School of Dentistry (2)

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ORANGE COUNTY-CONTRACT CONTROL SHEET Routing Order : ( 1 ) Department, (2 ) IT , (3 ) Risk Management, (4 ) Financial Services , ( 5 ) Attorney, ( 6 ) Manager, (7 ) Clerk This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above . If the Manager determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval . Contracts for BOCC approval must be submitted through , and complete , the routing process prior to agenda review . Contracts for legal review should be completed through the legal review process prior to being routed for signature . Department Party/Vendor Name : Unc School of Dentistry Party/Vendor Contact Person : Martha B . Barbour Contact Phone : Party/Vendor Address : 3150 Old Dental bldg City Chapel Hill State : NC Zip : 27599 Department : Public Health Amount : $ 56 , 848 Purpose : Provider will provide one or more postgraduate year one or two level in the Dental Health Services Divsions to provide ambulatory dental services for the academic year 2014 -2015 Budget Code (s ) : 10410420 - 630000 Vendor # 36302 (N/A if new vendor) Vendor is a BOCC consultant? Yes ❑ No ® Contract Type : (Check one) New ❑ Renewal ® Amendment ❑ Effective Date July 1 , 2014 Approved by Board Yes ❑ No ❑ Agenda Date : July 1 , 2014 - June 30 , 2015 Title of Contract . Graduate Resident Services If this is a Grant Agreement, pre - application has been approved by the Board of Commissioners Yes ❑ No ❑ . If submitted for bid were bids/RFPs received Yes ❑ No ❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to technical content : q4 0FE kalve &400 4 j Department Director ' s Signature : 4 Date : [ ' y Director (Applicable on y e/so are purchases or related services) This contract has been reviewed and approved by the n ormation Technology Director as to technical content an in hnology specifications : eete�-'s ig Date , Risk Management Include the following coverages : ❑ CGL ; ❑ Autos ❑ WC ; ❑ Professional ; ❑ Property ; OR No Insurance Required ❑ . Hold Contract pending receipt of Certificate of Insurance ❑ . With incorporation of Insurance provisions as sho is contract is approved by the Risk Manager : Risk Manager ' s Signature : �,��--- Date : DEC - 9 2014 Financial Services This Contract is conditioned Vpon appropriation by the Board of Commissioners Yes ❑ Noll/ A bu ptamendment is necessary before approval Yes ❑ No [ . If budget amendment is necessary, please attach to this form . This instrument has een )remonauctited manner required by the Local Government Budget and Fiscal Control Act : Financial Services Director ' s Signature : Om' # AOU Date : County Attorney_ Approval by Board ❑ (Contracts $ 90 , 000 . 00 or more for goods or services , $ 250 , 000 . 00 or more for construction , or any BOCC consultant contract) . Approval by an ger Most other contracts $ 1 , 000 and above) . Department Director approval only ❑ (Under $ 1 , 000 ) . This contract has been re ew and pr ed by the Attorney as to legal form and sufficiency : Attorney ' s Signature Date : County Manager This contract has been reviewed and is approved by the County Manager Yes No ❑ . This contract has been reviewed and i r signa e b the Ch�air� Yes ❑ No ❑ . Managers Signature : Date : Clerk to the Board Approved by BOCC on the day of , 20.. Submitted for Chair signature on the day of , 20 Clerk ' s Signature : Date : Revised March 2012