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Revised 06/21 <br />ORANGE COUNTY—DEPARTMENT USE ONLY <br />______________________________________________________________________________ <br /> <br />Party/Vendor Name: UNC Healthcare System Party/Vendor Contact Person: Kathryn Grant Contact Phone: 984- <br />974-1274 Party/Vendor Address: 5221 Paramount Parkway, Suite 420 City Morrisville State: NC Zip: 27560 <br />Department: Health Amount: $5,000 Purpose: BCCCP Mammogram Screening Budget Code(s): 10414020- <br />631010-71401 Vendor # 30892 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract <br />Type: (Check one) New Renewal Amendment Effective Date 7-1-22 Approved by Board Yes No <br />Agenda Date: --- For Section XIV. c. contracts only, Approved by Board in Current FY Budget Yes No <br /> <br />This agreement is approved as to technical form and content and I as Department Director affirmatively state work <br />on this project has not been initiated prior to execution of the agreement: <br /> <br />Department Director’s Signature ________________________________________ Date: ________ <br />Agreements for emergency services or repair are not subject to the above affirmation. If services related to this <br />agreement have already begun or been completed please briefly describe the nature of the emergency condition that <br />was addressed: <br /> <br />Information Technologies <br /> <br />(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is <br />approved as to information technology content and specifications: <br /> <br />Office of the Chief Information Officer___________________________________ Date: ________ <br /> <br />Risk Management <br /> <br />This agreement is approved for sufficiency of insurance standards, specifications, and requirements: <br /> <br />Office of the Risk Management Officer___________________________________ Date: _________ <br /> <br />Financial Services <br /> <br />This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control <br />Act: <br /> <br />Office of the Chief Financial Officer ____________________________________ Date: _________ <br /> <br />Legal Services <br /> <br />This agreement is approved as to legal form and sufficiency: <br /> <br />Office of the County Attorney __________________________________________Date: ________ <br /> <br />Clerk to the Board <br /> <br />Received for record retention: <br />All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov <br />The following signature block is for hard copies only and is not required for Docusign contracts: <br /> <br />Office of the Clerk to the Board __________________________________________Date:_________ <br />DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18 <br />7/28/2022 <br />7/28/2022 <br />7/28/2022 <br />7/28/2022