Extracted text (via ocr_local)
3848 characters
Book i FY 23
ARIZONA DEPARTMENT
OF HEALTH SERVICES
PREPAREDNESS we?
if
TUBERCULOSIS CONTROL - INCENTIVE PROGRAM - INCENTIVE REQUEST
SUBMIT THIS FORM to the Arizona Department of Health Services (ADHS) Tuberculosis
(TB) Control Program via the form found at the following URL: Request Submission
Bashas' Walmart Chevron
Total number of $10.00 cards requested 200° 208] am
ack
Total value ($) of cards requested OZ
($) vi $2000... {2 030
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Initials of program sh
representative:
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The cards will be used solely as incentives for clients receiving anti-TB treatment. Active ID
cases of TB will have the highest priority; however, if warranted these cards can be offered
to high-risk contacts, particularly children receiving treatment for LTBI.
The program will keep a record (tracking log) of every card dispensed and record the name ID
of the recipient, DOB, TB case/Infected contact/high risk person with LTBI, contact
information, date.
The program will submit a quarterly report to ADHS utilizing the template that can be ID
found at the following link: Download Report Template
Program Representative Contact Issmene Delgado 602-372-1 485
Name, Phone, Email
Director or DON Contact Corinne Velasquez
Name, Phone, Email
Physical Address Where Cards Should be 1645 E Roosevelt St, PHX., AZ 85006
Sent (Cannot be a PO Box)
+ Digitally signed by Issmeno
lesmene Delgady 2s nme 1/26/2023
_ Signature of Program Representative : Date
Corinne Velasquez: veeswer a 1/26/2023
Date: 2023.01.26 13:22:11 -07'00"
Signature of Director or DON Date
Douglas A. Ducey | Governor Don Herrington | Interim Director
150 North 18th Avenue, Sulte 500, Phoenix, AZ 85007-3247 P| 602-542-1025 F | 602-542-0883 W | azhealth.gov
Health and Wellness for all Arizonans
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ARIZONA DEPARTMENT
OF HEALTH SERVICES gayest fited rsnted.
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PREPAREDNESS Only hove acs
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TUBERCULOSIS CONTROL - INCENTIVE PROGRAM - INCENTIVE REQUEST
SUBMIT THIS FORM to the Arizona Department of Health Services (ADHS) Tuberculosis
(TB) Control Program via the form found at the following URL: Request Submission
Bashas'
Walmart
Chevron
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Total number of $10.00 cards requested Taal
eg O5 00.
Total value ($) of cards requested
Initials of program
representative:
The cards will be used solely as incentives for clients receiving anti-TB treatment. Active cvhb
cases of TB will have the highest priority; however, if warranted these cards can be offered
to high-risk contacts, particularly children receiving treatment for LTBI.
The program will keep a record (tracking log) of every card dispensed and record the name |cvhb
of the recipient, DOB, TB case/infected contact/high risk person with LTBI, contact
information, date.
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The program will submit a quarterly report to ADHS utilizing the template that can be
found at the following link: Download Report Template
Program Representative Contact
Name, Phone, Email
Charlotte Hunter-Brown
Director or DON Contact
Name, Phone, Email
Corinne Velasquez Corinne. Velasquez@maricopa.gov
Physical Address Where Cards Should be
1645 E. Roosevelt Phoenix,
AZ 85006
Sent (Cannot be a PO Box)
Charlotte Hunter-Brown 07/01/2022
Signature of Program Representative Date ‘
Corinne Velasquez 722
Signature of Director or DON Date
Douglas A. Ducey | Governor
Don Herrington | Interim Director
150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247
P | 602-542-1025
Health and Wellness for all Arizonans
F | 602-542-0883
W | azhealth.gov
ATTACHED TO AND A PART OF:
Tuberculosis Control Incentive Program
Acceptance and Use of Gift Cards
IN WITNESS WHEREOF, the parties agree to enter into this Agreement:
FOR AND ON BEHALF OF
MARICOPA COUNTY
By
Chairman, Board of Supervisors
Date
ATTEST:
Clerk of the Board
Date
APPROVED AS TO FORM
Attorney for Maricopa County
Date