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MCDPH Tuberculosis Program C-86-19- ARIZONA DEPARTMENT .„) 5 I OF HEALTH SERVICES 12fi'llt' P flAt PREPAREDNESS itoBravo TB a filitgProgram mmoor TUBERCULOSIS CONTROL — INCENTIVE PROGRAM — INCENTIVE REQUEST SUBMIT THIS FORM to the Arizona Department of Health Services (ADHS) Tuberculosis (TB) Control Program by fax (602) 364 -3267 or email kara.tarter@azdhs.gov . If you have any questions regarding this form, please call (602) 364-4750. Bashas' WaInnart Chevron Total number of $10.00 vouchers requested 500 Total value ($) of vouchers requested $ 5,000 Initials of program The vouchers will be used solely as incentives for clients receiving anti-TB treatment. representative: Active cases of TB will have the highest priority; however, if warranted these vouchers can be offered to high-risk contacts, particularly children receiving treatment for LTBI. AB Initials of program The program will keep a record (tracking log) of every voucher dispensed and record representative: the name of recipient, DOB, TB case/infected contact/high risk person with LTBI, contact information, date. AB Initials of program The program will submit a monthly report to ADHS listing the number of vouchers representative: distributed, the number of patients who received vouchers, and number of vouchers distributed YTD. AB Cornments: Program Representative Contact Name, phone#, email Angelito Bravo, 602 -372-1013, Angelito.Bravo@maricopa.gov Director or DON Contact Name, phonell, email Angelito Bravo Digitally signed by Angelito Bravo 05/06/2019 Date: 2019.05.06 10:02:37-0700 Signature of Program Representative Date Signature of Director or DON Date Date received by ADHS: Douglas A. Ducey I Governor Cara M. Christ, MD, MS I Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P 1 602-542- 1025 F 1602-542-1062 WI azhealth.gov Health and Wellness for all Arizonans = I )1 2,06 ARIZONA TD HE Ps ARM CEENST it g-0-11 , e ,,, , ,,e) 1111111 PREPAREDNESS ".,41100tavo . Tea ReiugeePtogrernMaraP TUBERCULOSIS CONTROL — INCENTIVE PROGRAM — INCENTIVE REQUEST SUBMIT THIS FORM to the Arizona Department of Health Services (ADHS) Tuberculosis (TB) Control Program by fax (602) 364-3267 or email Mary.Gulliongazdhs.gov . If you have any questions regarding this form, please call (602) 364-4750. Walmart Total number of $25.00 vouchers requested 80 Total value ($) of vouchers requested $2,000 Initials of program The vouchers will be used solely as incentives for clients receiving anti -TB treatment. representative: Active cases of TB will have the highest priority; however, if warranted these vouchers can be offered to high-risk contacts, particularly children receiving treatment for LTBI. AB Initials of program The program will keep a record (tracking log) of every voucher dispensed and record representative: the name of recipient, DOB, TB case/infected contact/high risk person with LTBI, contact information, date. AB Initials of program The program will submit a monthly report to ADHS listing the number of vouchers representative: distributed, the number of patients who received vouchers, and number of vouchers d istributed YTD. AB Comments: Program Representative Contact Angelito Bravo, 602-372-1013, AngelitoBravo@maricopa.gov Name, phone#, email Director or DON Contact Name, phone#, email Angelito Bravo DiyitalIy Dale: 2019.02.191047,47 9491ed by Anaerlo -02'00' Bravo 2/19/2019 Signature of Program Representative Date Signature of Director or DON Date Date received by ADHS: Douglas A. Ducey I Governor Cara M. Christ, MD, MS I Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P I 602-542-1025 F1602-542-1062 W I azhealth.gov Health and Wellness for all Arizonans IMIIIIII ARIZONA DEPARTMENT OF HEALTH SERVICES 117 iiiriridiHrt TUBERCULOSIS CONTROL — INCENTIVE PROGRAM — INCENTIVE REQUEST SUBMIT THIS FORM to the Arizona Department of Health Services (ADHS) Tuberculosis (TB) Control Program by fax (602) 364 -3267 or email kristen.herrick@azdhs.gov . If you have any questions regarding this form, please call (602) 364-4750. Walmart Total number of vouchers requested 80 ($25 denomination) Total value ($) of vouchers requested $2000 Initials of program The vouchers will be used solely as incentives for clients receiving anti-TB treatment. representative: Active cases of TB will have the highest priority; however, if warranted these vouchers can be offered to high-risk contacts, particularly children receiving treatment for LTBI. AB Initials of program The program will keep a record (tracking log) of every voucher dispensed and record representative: the name of recipient, DOB, TB case/infected contact/high risk person with LTBI, contact information, date. AB Initials of program The program will submit a monthly report to ADHS listing the number of vouchers representative: distributed, the number of patients who received vouchers, and number of vouchers distributed YTD. AB Cornments: Program Representative Contact Angelito Bravo, 602-372-1013, Angelito.Bravo@nnaricopa.gov Name, phone#, email Director or DON Contact Name, phonek email Angelito Bravo bate: 2018.09.11 s,grd tyAngeRo 09:40 -2I -0700' Era., 9/11/2018 Signature of Program Representative Date Signature of Director or DON Date Date received by ADHS: Douglas A. Ducey I Governor Cara M. Christ, MD, MS I Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P I 602-542-1025 F I 602-542-1062 W I azhealth.gov Health and Wellness for all Arizonans WWII ARIZONA DEPARTMENT 1 OF HEALTH SERVICES P1 PREPAREDNESS TUBERCULOSIS CONTROL— INCENTIVE PROGRAM — INCENTIVE REQUEST SUBMIT THIS FORM to the Arizona Department of Health Services (ADHS) Tuberculosis (TB) Control Program by fax (602) 364-3267 or email kristen.herrick@azdhs.gov . If you have any questions regarding this form, please call (602) 364-4750. Walmart Total number of vouchers requested 1 Total value ($) of vouchers requested $1000 ' Initials of program The vouchers will be used solely as incentives for clients receiving anti -TB treatment. representative: Active cases of TB will have the highest priority; however, if warranted these vouchers can be offered to high-risk contacts, particularly children receiving treatment for LTB1. AB Initials of program The program will keep a record (tracking log) of every voucher dispensed and record representative: the name of recipient, DOB, TB case/infected contact/high risk person with LTBI, contact information, date. AB Initials of program The program will submit a monthly report to ADHS listing the number of vouchers representative: distributed, the number of patients who received vouchers, and number of vouchers distributed YTD. AB Comments: Program Representative Contact Angelito Bravo 602-372-1013 AngelitoBravo@maii.mancopa.gov Name, phone#, email Director or DON Contact Name, phone#, email Angelito Bravo Ostally Date: 20Ia ugned 08.02 by 0020:43 PneLlo -0700' Bra. 8/2/2018 Signature of Program Representative Date Signature of Director or DON Date Date received by ADHS: Douglas A. Ducey I Governor Cara M. Christ, MD, MS I Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P1602-542-1025 F I 602-542-1062 W1azhealth.gov Health and Wellness for all Arizonans TB Incentive FY2019 total of $14,000.00 C-86-19- IN WITNESS WHEREOF, the parties agree: FOR AND ON BEHALF OF MARICOPA COUNTY By: ____________________________ Bill Gates, Chairman Board of Supervisors Date: ___________________________ ATTEST: By: ____________________________ Office of the Clerk of the Board Date: ___________________________ APPROVED AS TO FORM: By: ____________________________ Attorney for Maricopa County Date: __________________________