Laserfiche WebLink
018 <br />Division of Public Health <br />Agreement Addendum <br />FY 1647 <br />Page 1 of 2 <br />Women's and Children's Health <br />Lee County Health Department Section/Women's Health Branch <br />Local Health Department Legal Name DPH Section/Branch Name <br />Renee Jackson, 919-707-5714, <br />165 Infant Mortality Reduction reneej kson@dhhs.nc.gov <br />Activity Number and Description DPH Program Contact <br />(name, telephone number with area code, and email) <br />06/01/2016 — 05/31/2017 <br />Service Period <br />07/01/2016 — 06/30/2017 <br />DPH Program Signature Date <br />(only required for a ne otg iable agreement addendum) <br />Payment Period <br />❑ Original Agreement Addendum <br />® Agreement Addendum Revision # 1 (Please do not put the Budgetary Estimate revision # here.) <br />I. Background: <br />No change. <br />II. Purpose: <br />This Agreement Addendum Revision #1 provides additional funding for the Local Health Department to <br />expand upon its program activities as described in Section III below. This Agreement Addendum <br />Revision #1 also includes additional requirements in Section IV below. <br />III. Scope of Work and Deliverables: <br />As of November 1, 2016, Agreement Addendum Revision #1 adds Subparagraph a to Paragraph 4, as <br />follows: <br />a. If the Local Health Department has chosen to implement Long Acting Reversible <br />Contraception (LARC) as an evidence -based strategy, it shall track the following data: <br />i. Number of unduplicated females receiving LARC insertions by age group and LARC <br />methods using the following age group ranges: under 15; 15 to 17; 18 to 19; 20 to 24; <br />25 to 29; 30 to 34; 35 to 39; 40 to 44; and over 44. LARC methods are based upon <br />methods the Local Health Department purchased under Activity 165. <br />ii. Number of unduplicated females receiving LARC insertions by race and ethnicity. The <br />race groups are: American Indian or Alaska Native; Asian; Black or African American; <br />Native American or Other Pacific Islander; White; More than one race; and <br />Unknown/Not Reported. The ethnic groups are: Hispanic/Latino, Not-Hispanic/Latino, or <br />Unknown/Not Reported. <br />Health Director Signature (use blue ink) <br />Local Health Department to complete: LHD program contact name: <br />(If follow-up information is needed by DPH) Phone number with area code: <br />Email address: <br />Date <br />Signature on this nage signifies you have read and accepted all pages of this document. <br />Revised July 2015 <br />