Women, Infant and Community Wellness Section: Agreement Addenda, Audit Tools and Budget Forms
The Women, Infant and Community Wellness Section created the Agreement Addenda to guide clinical and support services through the best practices of care, as well as the legal requirements of staffing, quality and quantity of services.
The Agreement Addenda are static documents for one year. Both the current and previous fiscal year's agreement addenda and auditing tools are provided for your convenience. Information will be updated as it becomes available.
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FY 2022-2023 Agreement Addenda, Audit Tools, and Budget Forms - 10/11/22
FY 2022-2023 Family Planning Agreement Addenda + Audit Tools - 10/05/22
- Family Planning Agreement Addenda (PDF, 310 KB) 03/08/22
- Resources for Advancing Health Equity - September 2021 (PDF, 329 KB) 09/14/21
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Family Planning Agreement Addenda Audit Tools - 08/15/22
- NC Program Review Tool Interim (DOCX, 151 KB)
- Female Record (DOC, 217 KB)
- Male Record (DOC, 171 KB)
- Family Planning Outcome Objectives (OOs) by Objective Topic 2022-2023 (PDF, 12 MB) 03/21/22
- Family Planning Outcome Objectives (OOs) by County 2022-2023 (PDF, 51 MB) 10/06/22
- FPAR Data Requirement Guide (PDF, 212 KB) 07/23/21
- TANF Expenditure Examples/Ideas (PDF, 91 KB) 06/11/19
- Memorandum of Understanding (MOU) Family Planning Assurance Plan - Contact your Women’s Health Regional Nurse Consultant
FY 2022-2023 Maternal Health Agreement Addenda + Audit Tools - 10/11/22
- Maternal Health Agreement Addenda (PDF, 351 KB)
- 3954 - Maternal Health Agreement Addenda Audit Tool (PDF, 231 KB) 07/01/22
- Resources for Advancing Health Equity - September 2021 (PDF, 329 KB) 09/14/21
- DHHS 4153 - Home Visit for Postnatal Assessment and Follow-Up Audit Tool (PDF, 184 KB) 10/11/22
- Maternal Health Outcome Objectives (OOs) by Objective Topic 2022-2023 (PDF, MB)
- Maternal Health Outcome Objectives (OOs) by County 2022-2023 (PDF, MB)
FY 2022-2023 Maternal Health Assuring Agencies + Audit Tools 07/01/22
- Guidelines for Local Health Departments Assuring Maternal Health Services (PDF, 91 KB)
- Sample Assurance Plan Memorandum of Understanding (PDF, 77 KB)
- DHHS 4150 - Agencies Assuring Maternal Health Care Audit Tool (PDF, 107 KB) 07/01/22
FY 2022-2023 High Risk Maternity Clinic Agreement Addenda + Audit Tools - 07/01/22
- High Risk Maternity Clinic Agreement Addenda (PDF, 340 KB) 03/08/22
- Resources for Advancing Health Equity - September 2021 (PDF, 329 KB) 09/14/21
- DHHS 4148 - High Risk Maternity Clinic Agreement Addenda Audit Tool (PDF, 228 KB) 07/01/22
Health Behavior Intervention Audit Tool
Health Behavior Intervention Audit Tool (DHHS 4149) (PDF, KB)
Budget Forms FY 2022-2023 - 03/08/22
- Open Window Budget Form FY 2022-2023 (XLS, 1 MB)
- How to Fill Out the Open Window Budget Form (DOC, 252 KB)
FY 2021-2022 Agreement Addenda, Audit Tools, and Budget Forms - 11/01/21
FY 2021-2022 Family Planning Agreement Addenda + Audit Tools - 08/15/22
- Family Planning Agreement Addenda (PDF, 310 KB) - 02/15/21
- Resources for Advancing Health Equity - September 2021 (PDF, 329 KB) 09/14/21
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Family Planning Agreement Addenda Audit Tools – 07/23/21
- NC Program Review Tool (DOCX, 164 KB) 08/15/21
- Female Record (DOC, 213 KB)
- Male Record (DOC, 168 KB)
- Family Planning Outcome Objectives (OOs) by Objective Topic 2021-2022 (PDF, 2 MB) 03/25/21
- Family Planning Outcome Objectives (OOs) by County 2021-2022 (PDF, 1.6 MB) 03/04/21
- FPAR Data Requirement Guide (PDF, 212 KB) 07/23/21
- TANF Expenditure Examples/Ideas (PDF, 91 KB) 06/11/19
- Memorandum of Understanding (MOU) Family Planning Assurance Plan - Contact your Women’s Health Regional Nurse Consultant
FY 2021-2022 Maternal Health Agreement Addenda + Audit Tools - 09/14/21
- Maternal Health Agreement Addenda (PDF, 272 KB) 03/25/21
- DHHS 3954 - Maternal Health Agreement Addenda Audit Tool (PDF, 240 KB) 7/26/21
- Resources for Advancing Health Equity - September 2021 (PDF, 329 KB) 09/14/21
- DHHS 4153 - Home Visit for Postnatal Assessment and Follow-Up Audit Tool (PDF, 208 KB) 07/26/21
- Maternal Health Outcome Objectives (OOs) by Objective Topic 2021-2022 (PDF, 1.46 MB) 07/20/21
- Maternal Health Outcome Objectives (OOs) by County 2021-2022 (PDF, 2.50 MB) 07/20/21
FY 2021-2022 Maternal Health Assuring Agencies + Audit Tools - 07/26/21
- Guidelines for Local Health Departments Assuring Maternal Health Services (PDF, 53 KB) 03/25/21
- Sample Assurance Plan Memorandum of Understanding (PDF, 145 KB) 03/25/21
- DHHS 4150 - Agencies Assuring Maternal Health Care Audit Tool (PDF, 164 KB) 07/26/21
FY 2021-2022 High Risk Maternity Clinic Agreement Addenda + Audit Tools - 09/14/21
- High Risk Maternity Clinic Agreement Addenda (PDF, 319 KB) 03/25/21
- Resources for Advancing Health Equity - September 2021 (PDF, 329 KB) 09/14/21
- DHHS 4148 - High Risk Maternity Clinic Agreement Addenda Audit Tool (PDF, 237 KB) 07/26/21
Health Behavior Intervention Audit Tool - 11/01/21
Health Behavior Intervention Audit Tool (DHHS 4149) (PDF, 175 KB)
Budget Forms FY 2021-2022 - 02/15/21
- Open Window Budget Form FY 2021-2022 (XLS, 1 MB)
- How to Fill Out the Open Window Budget Form (DOC, 252 KB)
Last Modified: 10-11-2022