ZIP in the LHD’s jurisdiction (please list all, separating each with a comma) What RUCA codes does your agency’s jurisdiction cover? Current number of staff: full-time equivalents (FTEs) CONTRACT INFORMATION Selected LHDs will enter into a contract with NACCHO to complete the deliverable(s) outlined in the RFP. To expedite the contracting process for selected sites, agreement with NACCHO standard contract terms and conditions is a requirement for application. No modifications will be made. The information below will help to begin the contracting process immediately upon selection. The LHD (or entity that will be contracting Yes with NACCHO, e.g., city government), No including any relevant financial or legal offices, has read NACCHO’s standard contract language and would be able to enter into a contract without making modifications to the terms and conditions. The LHD (or contracting entity) will be able to Yes sign and return a contract to NACCHO within No 20 calendar days of receipt. If you selected to either of the above, ‘No’ please explain. TEAM INFORMATION Partner 1: LHD Primary contact name and Name: information Email: Title: Partner 2 Information Name:
ZIP in the LHD’s jurisdiction (please list all, separating each with a comma) What RUCA codes does your agency’s jurisdiction cover? Current number of staff: full-time equivalents (FTEs) CONTRACT INFORMATION Selected LHDs will enter into a contract with NACCHO to complete the deliverable(s) outlined in the RFP. To expedite the contracting process for selected sites, agreement with NACCHO standard contract terms and conditions is a requirement for application. No modifications will be made. The information below will help to begin the contracting process immediately upon selection. The LHD (or entity that will be contracting with NACCHO, e.g., city government), including any relevant financial or legal offices, has read NACCHO’s standard contract language and would be able to enter into a contract without making modifications to the terms and conditions. Yes No The LHD (or contracting entity) will be able to sign and return a contract to NACCHO within 20 calendar days of receipt. Yes No If you selected ‘No’ to either of the above, please explain. TEAM INFORMATION Partner 1: LHD Primary contact name and information Name: Email: Title: Partner 2 Information Name:
Application-Document-RURAL-SDOH.docx