HomeMy WebLinkAboutMINUTES - 12191995 - C73 TO: BOARD OF SUPERVISORS' °� ✓
FROM: Mark Finucane, Health Services Director Contra
Costa
DATE: December 7, 1995 Cou Ily
SUBJECT: Approval of Standard Contract #25-510 with Juliette Kelley
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
I. RECOMMENDED ACTION:
Approve and authorize the Health Services Director, or his designee
(Mary Foran) , to execute on behalf of the County, Standard Contract
#25-510 with Juliette Kelley, for the period from December 18, 1995
through December 17, 1996, with a payment limit of $47, 022 , for
consultation and technical assistance with regard to MCAH programs and
Year 2000 objectives.
II. FINANCIAL IMPACT:
This Contract is 100% funded by State and Federal sources. No County
funds are required.
III. REASONS FOR RECOMMENDATIONS/BACKGROUND:
Under Standard Contract 25-510 the Contractor will assist the
Department's Office of Service Integration - MCH Project with
planning, implementation, and evaluation of projects to improve
coordination among MCAH programs and to achieve Year 2000 Objectives,
especially for improved health status of families. The accomplishment
of the scope of work for the MCH Contract depends on the staffing to
be provided by this contractor.
Approval of this Contract will allow the Contractor to provide
services through December 17, 1996.
CONTINUED ON ATTACHMENT: YES SIGNATURE: A'a
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S)
ACTION OF BOARD ON 9 APPROVED AS RECOMMENDED OTHER
VOTE OF SUPERVISORS
V/ UNANIMOUS (ABSENT ) I HEREBY CERTIFY THAT THIS IS A TRUE
AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN
ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD
OF SUPERVISORS ON THE DATE SHOWN.
Contact: Mary Foran (313-6254)
CC:. Health Services (Contracts) ATTESTED
Risk Management Phil Batehelor,Cleric of the Board
Auditor-Controller Supervisors and County Administrator
Contractor
M302/7-83 BY ' DEPUTY
Contra Costa County Number ' 25-510
Standard Form 1/87 STANDARD CONTRACT Fund/Org # 5826
(Purchase of Services) Account # 2310
1. Contract Identification. Other #
Department: Health Services - Office for Service Integration
Subject: Consultation and technical assistance with regard to
MCAH programs and Year 2000 objectives
2. Parties. The County of Contra Costa, California (County) , for its Department named
above, and the following named Contractor mutually agree and promise as follows:
Contractor: JULIETTE KELLEY
Capacity: Self-employed Individual axpayer ID # 549-04-1495
Address: 6 Glen Avenue, Oakland,. California 94611
3. Term. The effective date of this Contract is December 18. 1995 , and it
terminates December 17. 1996 unless sooner terminated as provided herein.
4. Payment Limit. County's total payments to Contractor under this Contract shall not
exceed4S 7,022.
5. County's Obligations. County shall make to the Contractor those payments described in
the Payment Provisions attached hereto which are incorporated herein by reference,
subject to all the terms and conditions contained or incorporated herein.
6. Contractor's Obligations. Contractor shall provide those services and carry out that
work described in the Service Plan attached hereto which is incorporated herein by
reference, subject to all the terms and conditions contained or incorporated herein.
7. General and Special Conditions. This Contract is subject to the General Conditions and
Special Conditions (if any) attached hereto, which are incorporated herein by
reference.
8. Project. This Contract implements in whole or in part the following described Project,
the application and approval documents of which are incorporated herein by reference:
County's current Standard Agreement #29-265-34 with the State Department of Health
Services for the Maternal and Child Health, a copy of which is on. file in the
administrative of.Lice of the County's Public Health Division and which is incorporated
herein by refer and any modifications or revisions thereof.
9. Legal Authority. ct is entered into under and subject to the following
legal authorities: Cal Ifo
iia Government Code §§ 26227 and 31000.
10. Signatures. These signatures attest the parties' agreement hereto:
COUNTY OF CONTRA COSTA, CALIFORNIA
ATTEST: Phil Batchelor, Clerk of the Board
BOARD OF SUPERVISORS of Supervisors and County Administrator
By By
Chairman/Designee Deputy
CONTRACTOR
By By
Self-employed individual
(Designate business capacity A) (Designate business capacity B)
Note to Contractor: For corporations (profit or nonprofit), the contract must be signed by two officers. Signature A must be
that of the president or vice-president and Signature B must be that of the secretary or assistant secretary (Civil Code S 1190
and Corporations Code S 313). All signatures must be acknowledged as set forth on page two.
Contra Costa County Standard Form(Rev. 1/95)
APPRO V ALS/A CKNO WLEDGM ENT
Number 25-510
APPROVALS
RECOMMENDED BY DEPARTMENT FORM APPROVED
!'/IT TATTV !'/IT TAT(�T
By By
Designee Deput
APPROVED: COUNTY ADMINISTRATOR
By:
Designee
ACKNOWLEDGMENT
STATE OF CALIFORNIA )
ss.
COUNTY OF CONTRA COSTA )
On , before me,
(insert name and title of the officer), personally appeared
personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s)whose name(s)
is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s)on the instrument the person(s), or the
entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS MY HAND AND OFFICIAL SEAL.
(Seal)
Signature
ACKNOWLEDGMENT(by Corpmtion, Partarship,or Individual)
(Civil Coda 11189)
Contra Costa County PAYMENT PROVISIONS Standard Form 6/90
(Fee Basis Contracts)
Number 25-510
1. Payment Amounts. Subject to the Payment Limit of this Contract and subject to the
following Payment Provisions, County will pay Contractor the following fee as full
compensation for all services, work, expenses or costs provided or incurred by
Contractor:
[Check one alternative only. ]
[ J a. $ monthly;
[ J b. $ per unit, as defined in the Service Plan;
[ ] c. $ after completion of all obligations and conditions herein; or
[X] d. $ 25.29 per hour, not to exceed 1,800 hours or a total of $45,522; and
In addition, County will reimburse Contractor an amount not to exceed $1,500,
as follows: (a) for conference registration and travel on behalf of the
County, approved in advance by the Director of the Office for Service
Integration; (b) for miscellaneous expenses actually incurred in the provision
of services hereunder during the term of this Contract; and (c) at the rate of
30 cents per mile for the use of a private automobile required in the
provision of services hereunder.
2. Payment Demands. Contractor shall submit written demands. Said demands shall be made
on County Demand Form D-15 and in the manner and form prescribed by County. Contractor
shall submit said demands for payment no later than 30 days from the end of the month
in which the contract services upon which such demand is based were actually rendered.
Upon approval of said payment demands by the head of the County Department for which
this Contract is made, or his designee, County will make payments as specified in
Paragraph 1. (Payment Amounts) above.
3. Penalty for Late Submission. When Contractor fails to submit to County a timely demand
for payment as specified in Paragraph 2. (Payment Demands) above, and as a result of
Contractor's late submission the County is unable to obtain reimbursement from the
State of California or otherwise; to the extent the County's recovery of funding is
prejudiced, County shall not pay Contractor for such services, even though such
services were fully provided.
4. Right to Withhold. County has the right to withhold payment to the Contractor when,
in the opinion of the County expressed in writing to the Contractor, (a) the
Contractor's performance, in whole or in part, either has not been carried out or is
insufficiently documented, (b) the Contractor has neglected, failed or refused to
furnish information or to cooperate with any inspection, review or audit of its
program, work or records, or (c) Contractor has failed to sufficiently itemize or
document its demand(s) for payment.
5. Audit Exceptions. Contractor agrees to accept responsibility for receiving, replying
to, and/or complying with any audit exceptions by appropriate County, State or Federal
audit agencies occurring as a result of its performance of this Contract. Contractor
also agrees to pay to the County within 30 days of demand by County the full amount of
the County's obligation, if any, to the State and/or Federal government resulting from
any audit exceptions, to the extent such are attributable to the Contractor's failure
to perform properly any of its obligations under this Contract.
Initials:
Contractor County Dept.
SERVICE PLAN
Number 25-510
1. Service Activities. During the term of this Contract, Contractor
shall assist the Health Services Director or his designee (Director of
Office for Service Integration / Maternal and Child Health (MCH)
Project Director) with regard to planning, implementing, and
evaluating projects to improve coordination among Maternal, Child, and
Adolescent Health (MCAH) programs and to achieve Year 2000 Objectives.
Contractor's services shall be in accordance with County's Standard
Agreement #29-265-34 (and any modifications or revisions thereof) ,
with the State Department of Health Services, a copy of which is on
file in the administrative office of the County's Public Health
Division, 597 Center Avenue, Suite 200, which is incorporated herein
by reference. Contractor's activities shall include, but may not be
limited to, the following:
a. Implementing a "Help Desk" to provide staff with easily
accessible and reliable information about referral services so
that families are connected more directly and easily with needed
services and support;
b. Participating, as requested by County, in design and
implementation of a county-wide human services Information and
Referral (I&R) system which expands the Help Desk access to
families county-wide;
C. Coordinating, in the time and manner requested by County, an
annual MCAH/Family Health needs assessment/planning process;
d. Developing new resources to address results of needs assessment
activities, including but not limited to improving transportation
from under-served neighborhoods to family and MCAH services, and
increasing availability of parent education and support
resources;
e. Producing fiscal research and consultation in the time, manner,
and form required by County, as it relates to various program
areas;
f. Assisting the Health Services Director or his designee, with
regard to evaluation, development, and planning for County
collaborative programs such as Family Maintenance Organization
and Service Integration Teams; and
g. Other tasks as required by the County.
2 . Performance Reports. Contractor shall prepare and submit to County
periodic performance progress reports in the time, form and manner
required by County's Health Services Department Director or his
designee.
Initials:
Contractor County Dept.
SPECIAL CONDITIONS
Number 25-510
1. Withholding and FICA Deductions. Notwithstanding Paragraph •14 of
the General Conditions, for purposes of withholding state and
federal taxes and Social Security only from payments due, the
Auditor-Controller will make deductions for these purposes.
Contractor is not a County employee. Contractor further
understands that the County has no obligation to provide, and the
Contractor will not be provided fringe benefits, including but not
limited to, vacation, sick leave, retirement, and health plan
coverage. The County will provide workers ' compensation coverage
and unemployment insurance if County has right to control way in
which work is done.
2 . Insurance. General Conditions Paragraph 19 . (Insurance) is hereby
deleted and replaced with a new paragraph to read as follows:
1119. Insurance. During the entire term of this Contract and any
extension or modification thereof, Contractor shall keep in
effect a policy or policies of motor vehicle liability
insurance for any use Contractor makes of a private motor
vehicle in the performance of this Contract, as required by
the State."
3 . Endorsements. Contractor shall not in its capacity as a contractor
with Contra Costa County publicly endorse or oppose the use of any
particular brand name or commercial product without the prior
approval of the Board of Supervisors. In its County contractor
capacity, Contractor shall not publicly attribute qualities or lack
of qualities to a particular brand name or commercial product in
the absence of a well-established and widely accepted scientific
basis for such claims or without the prior approval of the Board of
Supervisors. In its County contractor capacity, Contractor shall
not participate or appear in any commercially-produced
advertisements designed to promote a particular brand ' name or
commercial product, even if Contractor is not publicly endorsing a
product, as long as the Contractor's presence in the advertisement
can reasonably be interpreted as an endorsement of the product by
or on behalf of Contra Costa County. Notwithstanding the
foregoing, Contractor may express its views on products to other
contractors, the Board of Supervisors, County officers, or others
who may be authorized by the Board of Supervisors or by law to
receive such views.
Initials:
Contractor County Dept.
Contra Costa County Standard Form 1/87
GENERAL CONDITIONS
(Purchase of Services)
1. Compliance with Law. Contractor shall be subject to and comply with all Federal, State and local
laws and regulations applicable with respect to its performance under this Contract, including but not
limited to, licensing, employment and purchasing practices; and wages, hours and conditions of
employment, including nondiscrimination.
2. Inspection. Contractor's performance, place of business and records pertaining to this Contract
are subject to monitoring, inspection, review and audit by authorized representatives of the County, the
State of California, and the United States Government.
3. Records. Contractor shall keep and make available for inspection and copying by authorized
representatives of the County, the State of California, and the United States Government, the
Contractor's regular business records and such additional records pertaining to this Contract as may be
required by the County.
a. Retention of Records. The Contractor shall retain all documents pertaining to this Contract
for five years from the date of submission of Contractor's final payment demand or final Cost Report;
for any further period that is required by law; and until all Federal/State audits are complete and
exceptions resolved for this contract's funding period. Upon request, Contractor shall make these records
available to authorized representatives of the County, the State of California, and the United States
Government.
b. Access to Books and Records of Contractor, Subcontractor. Pursuant to Section 1861(v)(1)
of the Social Security Act, and any regulations promulgated thereunder, Contractor shall, upon written
request and until the expiration of four years after the furnishing of services pursuant to this Contract,
make available to the Secretary of Health and Human Services or to the Comptroller General, or any of
their duly authorized representatives, this Contract and books, documents, and records of Contractor
that are necessary to certify the nature and extent of all costs and charges hereunder.
Further, if Contractor carries out any of the duties of this Contract through a subcontract with a value
or cost of $10,000 or more over a twelve-month period, such subcontract shall contain a clause to the
effect that upon written request and until the expiration of four years after the furnishing of services
pursuant to such subcontract, the subcontractor shall make available, to the County, to the Secretary or
to the Comptroller General, or any of their duly authorized representatives, the subcontract and books,
documents, and records of the subcontractor that are necessary to verify the nature and extent of all.costs
and charges thereunder.
This special condition is in addition to any and all other terms regarding the maintenance or retention
of records under this Contract and is binding on the heirs, successors, assigns and representatives of
Contractor.
4. Reporting Requirements. Pursuant to Government Code Section 7550, Contractor shall include
in all documents or written reports completed and submitted to County in accordance with this Contract,
a separate section listing the numbers and dollar amounts of all contracts and subcontracts relating to
the preparation of each such document or written report. This section shall apply only if the payment
limit under this Contract exceeds $5,000.
1
Contra Costa County Standard Form 1/87
GENERAL CONDITIONS
(Purchase of Services)
5. Termination.
a. Written Notice. This Contract may be terminated,by either party, at their sole discretion,
upon thirty-day advance written notice thereof to the other, and may be cancelled immediately by written
mutual consent.
b. Failure to Perform. The County, upon written notice to Contractor, may immediately
.terminate this Contract should the Contractor fail to perform properly any of its obligations hereunder.
In the event of such termination, the County may proceed with the work in any reasonable manner it
chooses. The cost to the County of completing Contractor's performance shall be deducted from any sum
due the Contractor under this Contract, without prejudice to the County's rights otherwise to recover
its damages.
C. Cessation of Funding. Notwithstanding Paragraph 5.a. above, in the event that Federal,
State, or other non-County funding for this Contract ceases, this Contract is terminated without notice.
6. Entire Agreement. This Contract contains all the terms and conditions agreed upon by the parties.
Except as expressly provided herein, no other understanding, oral or otherwise, regarding the subject
matter of this Contract shall be deemed to exist or to bind any of the parties hereto.
7. Further Specifications for Operating Procedures. Detailed specifications of operating procedures
and budgets required by this Contract, including but not limited to, monitoring, evaluating, auditing,
billing, or regulatory changes, may be developed and set forth in a written Informal Agreement between
the Contractor and the County. Such Informal Agreements shall be designated as such and shall not be
amendments to this Contract except to the extent that they further detail or clarify that which is already
required hereunder. Such Informal Agreements may not enlarge in any manner the scope of this
Contract, including any sums of money to be paid the Contractor as provided herein. Informal
Agreements may be approved and signed by the head of the County Department for which this Contract
is made or his designee.
8. Modifications and Amendments.
a. General Amendments. This Contract may be modified or amended by a written document
executed by the Contractor and the Contra Costa County Board of Supervisors or, after Board approval,
by its designee, subject to any required State or Federal approval.
b. Administrative Amendments. Subject to the Payment Limit, the Payment Provisions and
the Service Plan may be amended by a written administrative amendment executed by the Contractor
and the County Administrator or his designee, subject to any required State or Federal approval,
provided that such administrative amendments may not materially change the Payment Provisions or the
Service Plan.
9. Disputes. Disagreements between the County and Contractor concerning the meaning,
requirements, or performance of this Contract shall be subject to final determination in writing by the
head of the County Department for which this Contract is made or his designee or in accordance with
the applicable procedures (if any) required by the State or Federal Government.
Contra Costa County Standard Form L87
GENERAL CONDITIONS
(Purchase of Services)
10. Choice of Law and Personal Jurisdiction.
a. This Contract is made in Contra Costa County and shall be governed and construed in
accordance with the laws of the State of California.
b. Any action relating to this Contract shall be instituted and prosecuted in the courts of
Contra Costa County, State of California.
11. Conformance with Federal and State Regulations and Laws. Should Federal or State regulations
or laws touching upon the subject of this Contract be adopted or revised during the term hereof, this
Contract shall be deemed amended to assure conformance with such Federal or State requirements.
12. No Waiver by County. Subject to Paragraph 9. (Disputes) of these General Conditions, inspections
or approvals, or statements by any officer, agent or employee of the County indicating the Contractor's
performance or any part thereof complies with the requirements of this Contract, or acceptance of the
whole or any part of said performance, or payments therefor, or any combination of these acts, shall not
relieve the Contractor's obligation to fulfill this Contract as prescribed; nor shall the County be thereby
estopped from bringing any action for damages or enforcement arising from any failure to comply with
any of the terms and conditions of this Contract.
13. Subcontract and Assignment. This Contract binds the heirs, successors, assigns and
representatives of Contractor. The Contractor shall not enter into subcontracts for any work
contemplated under this Contract and shall not assign this Contract or monies due or to become due,
without the prior written consent of the County Administrator or his designee, subject to any required
State or Federal approval.
14. Independent Contractor Status. This Contract is by and between two independent contractors and
is not intended to and shall not be construed to create the relationship between the parties of agent,
servant, employee, partnership, joint venture or association.
15. Conflicts of Interest. Contractor, its officers, partners, associates, agents, and employees, shall
not make, participate in making, or in any way attempt to use the position afforded them by this
Contract to influence any governmental decision in which he or she knows or has reason to know that
he or she has a financial interest under California Government Code Sections 87100, et seq., or
otherwise.
16. Confidentiality. Contractor agrees to comply and to require its officers, partners, associates,
agents and employees to comply with all applicable State or Federal statutes or regulations respecting
confidentiality, including but not limited to, the identity of persons served under this Contract, their
records, or services provided them, and assures that:
a. All applications and records concerning any individual made or kept by Contractor or any
public officer or agency in connection with the administration of or relating to services provided under
this Contract will be confidential, and will not be open to examination for any purpose not directly
connected with the administration of such service.
Contra Costa County Standard FOrm 1/87
GENERAL CONDITIONS
(Purchase of Services)
b. No person will publish or disclose or permit or cause to be published or disclosed, any list
of persons receiving services, except as may be required in the administration of such service. Contractor
agrees to inform all employees, agents and partners of the above provisions, and that any person
knowingly and intentionally disclosing such information other than as authorized by law may be guilty
of a misdemeanor.
17. Nondiscriminatory Services. Contractor agrees that all goods and services under this Contract
shall be available to all qualified persons regardless of age, sex, race, religion, color, national origin, or
ethnic background, or handicap, and that none shall be used, in whole or in part, for religious worship
or instruction.
18. Indemnification. The Contractor shall defend, indemnify,save, and hold harmless the County and
its officers and employees from any and all claims, costs and liability for any damages, sickness, death,
or injury to person(s) or property, including without limitation all consequential damages, from any cause
whatsoever arising directly or indirectly from or connected with the operations or services of the
Contractor or its agents, servants, employees or subcontractors hereunder, save and except claims or
Iitigation arising through the sole negligence or sole willful misconduct of the County or its officers or
employees. Contractor will reimburse the County for any expenditures, including reasonable attorneys'
fees, the County may make by reason of the matters that are the subject of this indemnification, and if
requested by the County will defend any claims or litigation to which this indemnification provision
applies at the sole cost and expense of the Contractor.
19. Insurance. During the entire term of this Contract and any extension or modification thereof, the
Contractor shall keep in effect insurance policies meeting the following insurance requirements unless
otherwise expressed in the Special Conditions:
a. Liability Insurance. The Contractor shall provide comprehensive liability insurance,
including coverage for owned and non-owned automobiles, with a minimum combined single limit
coverage of$ 00,000 for all damages, including consequential damages, due to bodily injury, sickness or
disease, or death to any person or damage to or destruction of property, including the loss of use thereof,
arising from each occurrence. Such insurance shall be endorsed to include the County and its officers
and employees as additional insureds as to all services performed by Contractor under this agreement.
Said policies shall constitute primary insurance as to the County, the State and Federal Governments,
and their officers, agents, and employees, so that other insurance policies held by them or their self-
insurance program(s) shall not be required to contribute to any loss covered under the Contractor's
insurance policy or policies.
b. Workers' Compensation. The Contractor shall provide workers' compensation insurance
coverage for its employees.
C. Certificate of Insurance. The Contractor shall provide the County with (a) certificates)
of insurance evidencing liability and worker's compensation insurance as required herein no later than
the effective date of this Contract. If the Contractor should renew the insurance policy(ies) or acquire
either a new insurance policy(ies) or amend the coverage afforded through an endorsement to the policy
at any time during the term of this Contract, then Contractor shall provide (a) current certificates) of
insurance.
A
Contra Costa County Standard Form 1/87
GENERAL CONDITIONS
(Purchase of Services)
d. Additional Insurance Provisions. The insurance policies provided by the Contractor shall
include a provision for thirty (30) days written notice to County before cancellation or material changes
of the above specified coverage.
20. Notices. All notices provided for by this Contract shall be in writing and may be delivered by
deposit in the United States mail, postage prepaid. Notices to the County shall be addressed to the head
of the County Department for which this Contract is made. Notices to the Contractor shall be
addressed to the Contractor's address designated herein. The effective date of notice shall be the date
of deposit in the mails or of other delivery, except that the effective date of notice to the County shall be
the date of receipt by the head of the County Department for which this Contract is made.
21. Primacy of General Conditions. Except for Special Conditions which expressly supersede General
Conditions, the Special Conditions (if any) and Service Plan do not limit any term of the General
Conditions.
22. Nonrenewal. Contractor understands and agrees that there is no representation, implication, or
understanding that the services provided by Contractor under this Contract will be purchased by County
under a new contract following expiration of termination of this Contract, and waives all rights or claims
to notice or hearing respecting any failure to continue purchase of all or any such services from
Contractor.
23. Possessory Interest. If this Contract results in the Contractor having" possession of, claim to or
right to the possession of land or improvements, but does not vest ownership of the land or improvements
in the same person, or if this Contract results in the placement of taxable improvements on tax exempt
land (Revenue & Taxation Code Section 107), such interest or improvements may represent a possessory
interest subject to property tax, and Contractor may be subject to the payment of property takes levied
on such interest. Contractor agrees that this provision complies with the notice requirements of Revenue
& Taxation Code Section 1.07.6, and waives all rights to further notice or to damages under that or any
comparable statute.
24. No Third-Party Beneficiaries. Notwithstanding mutual recognition that services under this
Contract may provide some aid or assistance to members of the County's population, it is not the
intention of either the County or Contractor that such individuals occupy the position of intended third-
party beneficiaries of the obligations assumed by either party to this Contract.
25. Copyrights and Rights in Data. Contractor shall not publish or transfer any materials produced
or resulting from activities supported by this agreement without the express written consent of the County
Administrator. If any material is subject to copyright, the County reserves the right to copyright such
and the Contractor agrees not to copyright such material. If the material is copyrighted, the County
reserves a royalty-free, nonexclusive, and irrevocable license to reproduce, publish, and use such
materials, in whole or in part, and to authorize others to do so.
QUESTIONNAIRE FOR DETERMINING INDEPENDENT
CONTRACTOR PAYMENT METHOD
All new or renewal independent contractor agreements that do not meet IRS criteria for
independent contract status must be paid- through the payroll system so that withholding
ta-ces and Social Security can be deducted by the County. Please complete the
following questionnaire for each self-employed individual with whom you intend to
contract (note: this form does not apply in the case of contracts with corporations,
temporary help agencies, partnerships or established businesses with a Taxpayer
Identification number) . ,c,�Q
CONTRACTOR NAME: u��. �/ C JI Social Security # "!-'/ ' Oil' I"1 5—
CONTRACT NUMBER:
YES NO
1. Do I, as the employer, have the right to
control not only the result of the work,
but also the way in which it is done?
2. Am I setting the independent contractor's
hours? (✓� ( )
3. Is the independent contractor restricted .
from taking jobs from other businesses
at the same time they are working for me? (Vf ( )
4. Do I or other departments have employee(s)
with similar duties as the independent /
contractor? ( vT ( )
5. Does the County supply assistants to the
contractor?
6. Is the duration of employment for a
specific period of time rather than a
specific job? ( ( )
7. Does the County furnish training, tools,
or equipment to the contractor? ( ( )
A "yes" answer to any of the above questions will constitute
justification for paying the contractor through the payroll
system.
CONTRACTOR APPROVAL: PUTARED BY:
The answers to the above questions
accurately reflect my anticipated X
working relationship with the County.
V ROVED BY:
Health Services Department
2/19/91