CDSA. Early Intervention Branch, Women’s and Children’s Health Section, Division of Public Health, North Carolina Department of Health and Human Services BY: Director or Designee TITLE: DATE: FEDERAL CERTIFICATIONS The undersigned states that:
CDSA. Service Provider Roster Name of Service Provider Agency I certify that this is a complete roster of all employees or subcontractors of my agency who are or will be providing services to infants, toddlers and families enrolled with the N.C. Infant-Toddler Program (N.C. ITP). I further certify that all employees / subcontractors listed below have the requisite current licensure and/or certification and shall maintain such licensure / certification to remain employed or serve as subcontractors for providing services to infants, toddlers and families enrolled in the N.C. ITP. If I employ new staff / subcontractors, I shall submit to the CDSA the additional names and licensure information for new staff / subcontractors along with copies of current licenses/certifications and signed Confidentiality Statement(s) within (2) business days of their employment. Printed Name of CEO or Owner of Service Provider Agency Signature Date of Signature Employee / Subcontractor Name Job Title Indicate Licensure or Certification and Expiration Date (if applicable) Assigned Counties [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] [Printed Name] [Licensure or Certification] [Printed] [Expiration Date] Service Provider Plan / Agreement Amendment
CDSA. Date Services to Begin (if submitting new Provider Agreement): / / Name of Service Provider Agency: Mailing Address: Telephone #: ( ) - Cellular Phone #: ( ) - Fax #: ( ) - Primary contact person: Email: Alternate contact person: Email: Service Provider Plan: COUNTY ITP SERVICE(S)* PROJECTED CAPACITY** *Indicate any of the following: PT, OT, SP, Special Instruction (CBRS), AUDIO **Indicate maximum number of ITP children/families you are able to serve in this county per service at any given time Printed Name of Authorized Representative Name of Service Provider Organization Signature of Authorized Representative Date of Signature Signature of CDSA Finance Officer Date of Signature Signature of CDSA Director Date of Signature Send Plan / Agreement Amendment to: For CDSA Use Only Insurances current? Prof / Gen / WC / Auto Y / N Date Initial Agreement Effective Effective Period of Renewal #1 Effective Period of Renewal #2 Agreement Termination Date Background/OIG check CHANGE REQUEST FORM (CDSA) Date: Service Provider Agency: Please fill out only the sections for which you are requesting changes.
CDSA. Early Intervention Branch, Women’s and Children’s Health Section, Division of Public Health, North Carolina Department of Health and Human Services BY: Director or Designee TITLE: DATE: FEDERAL CERTIFICATIONS The undersigned states that: He or she is the duly authorized representative of the Contractor named below; He or she is authorized to make, and does hereby make, the following certifications on behalf of the Contractor, as set out herein: The Certification Regarding Nondiscrimination; The Certification Regarding Drug-Free Workplace Requirements; The Certification Regarding Environmental Tobacco Smoke; The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions; and The Certification Regarding Lobbying; He or she has completed the Certification Regarding Drug-Free Workplace Requirements by providing the addresses at which the contract work will be performed; [Check the applicable statement] He or she has completed the attached Disclosure of Lobbying Activities because the Contractor has made, or has an agreement to make, a payment to a lobbying entity for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action; OR He or she has not completed the attached Disclosure of Lobbying Activities because the Contractor has not made, and has no agreement to make, any payment to any lobbying entity for influencing or attempting to influence any officer or employee of any agency, any Member of Congress, any officer or employee of Congress, or any employee of a Member of Congress in connection with a covered Federal action. The Contractor shall require its subcontractors, if any, to make the same certifications and disclosure. ____________________________________________________________________________________________________________ Signature Title ____________________________________________________________________________________________________________ Contractor [Organization’s] Legal Name Date [This Certification must be signed by a representative of the Contractor who is authorized to sign contracts.]
CDSA. MPAA FACT UK Shared Assessments FISC Japan HIPAA / HITECH Act HITRUST GxP 21 CFR Part 11 MARS-E IG Toolkit UK FERPA GLBA FFIEC Argentina EU UK China China China Singapore Australia New Zealand Japan My ENISA Japan CS Spain Spain India Canada Privacy Germany IT PDPA Model Clauses G-Cloud DJCP GB 18030 TRUCS MTCS IRAP/CCSL GCIO Number Act IAF Xxxx Xxxx ENS DPA MeitY Privacy Laws Shield Grundschutz workbook K12 Use Cases “The only way we can respond to the shift to digital that is sweeping through education is to use the cloud.” Xxxxx Xxxxxx: Director, Technology Operations Lake Washington School District School Challenges Solution Benefits Lake Washington School District large data storage system, which needed regular care, feeding, and refreshing. continued its move to the cloud and decommissioned on-premises resources Azure StorSimple, disaster recovery, Virtual Machines, Storage, Networking $200k in savings from new tape backup system, focus on educating kids rather than deploying servers, time savings, cost savings, dev/test Omaha Public Shools Tucson Unified School District Limited on-premise data warehousing solution, Conflicting and out-of-date reporting; limited budget, outdated infrastructure Azure SQL Database and PowerBI Near Real-time contextual data – qualitative and quantitative, more organized, meaningful data collection, visualization, and reporting. Entire data worklflow has been optimized; Improved Efficiency, more robust infrastructure, saved costs Tacoma Public Schools Turn at-risk students around, 55% on-time graduation rate Azure Data Factory, Storage, Machine Learning, Power BI Graduation rate jumped from 55 to 82.6 percent University Use Cases “I can only imagine what Microsoft solutions and AI technology in particular could have done for me earlier in my career. I think I could have gone further. And that’s what I want for our students. We’re working to create a fully accessible world.” Xxxx Xxxx: Director, Center on Access Technology, Rochester Institute of Technology School Challenges Solution Benefits RIT Student Learning Accessibility and Multi-modal learning Azure Cognitive Services and Translator (with technical term learning), Microsoft Custom Speech Service; Translator add-in Powerpoint Augments captionist staff; 10 Classroom deployment; multi-channel learning; multi- language learning Cambridg e Increase Student Learning and Preparation In Engineering Classes Python in Azure Notebooks powered by Jupyter Open Source Project F...
CDSA. Exception: for those who had correspondence with the PRIMED CC to update/correct the responses to Questions 1-4, please use the agreed upon updates.
