Appalachian District Health Department

Policy and Procedure Policy Name Management Operations Policy Topic Board of Health: Overall Operations

Section 200

Approved Date: BOH 3-8-08

Chapter 223

Revised Date: 2-16-13; 9-12-17

Purpose: To state general policies that will guide the Board of Health in its delegation of duties in compliance with NC General Statutes and other applicable rules and law. Policy: The Appalachian District Board of Health adopts the National Association of Local Boards of Health Six Functions of Public Health Governance, outlined below. Procedures to guide this policy are also outlined below. 1. Policy development: Lead and contribute to the development of policies that protect, promote, and improve public health while ensuring that the agency and its components remain consistent with the laws and rules (local, state, and federal) to which it is subject. These may include, but are not limited to: a. Developing internal and external policies that support public health agency goals and utilize the best available evidence; b. Adopting and ensuring enforcement of regulations that protect the health of the community; c. Developing and regularly updating vision, mission, goals, measurable outcomes, and values statements; d. Setting short- and long-term priorities and strategic plans; e. Ensuring that necessary policies exist, new policies are proposed/implemented where needed, and existing policies reflect evidence-based public health practices; and f. Evaluating existing policies on a regular basis to ensure that they are based on the best available evidence for public health practice. 2. Resource stewardship: Assure the availability of adequate resources (legal, financial, human, technological, and material) to perform essential public health services. These may include, but are not limited to: a. Ensuring adequate facilities and legal resources; b. Developing agreements to streamline cross-jurisdictional sharing of resources with neighboring governing entities; c. Developing or approving a budget that is aligned with identified agency needs; d. Engaging in sound long-range fiscal planning as part of strategic planning efforts; e. Exercising fiduciary care of the funds entrusted to the agency for its use; and f. Advocating for necessary funding to sustain public health agency activities, when appropriate, from approving/appropriating authorities. 3. Legal authority: Exercise legal authority as applicable by law and understand the roles, responsibilities, obligations, and functions of the governing body, health officer, and agency staff. These may include, but are not limited to: 1|Management Operations – Board of Health: Overall Operations

Appalachian District Health Department

Policy and Procedure Policy Name Management Operations Policy Topic Board of Health: Overall Operations

Section 200

Approved Date: BOH 3-8-08

Chapter 223

Revised Date: 2-16-13 9-12-17

a. Ensuring that the governing body and its agency act ethically within the laws and rules (local, state, and federal) to which it is subject; b. Providing or arranging for the provision of quality core services to the population as mandated by law, through the public health agency or other implementing body; and c. Engaging legal counsel when appropriate. 4. Partner engagement: Build and strengthen community partnerships through education and engagement to ensure the collaboration of all relevant stakeholders in promoting and protecting the community’s health. These may include, but are not limited to: a. Representing a broad cross-section of the community; b. Leading and fully participating in open, constructive dialogue with a broad cross- section of members of the community regarding public health issues; c. Serving as a strong link between the public health agency, the community, and other stakeholder organizations; and d. Building linkages between the public and partners that can mitigate negative impacts and emphasize positive impacts of current health trends. 5. Continuous improvement: Routinely evaluate, monitor, and set measurable outcomes for improving community health status and the public health agency’s/governing body’s own ability to meet its responsibilities. These may include, but are not limited to: a. Assessing the health status of the community and achievement of the public health agency’s mission, including setting targets for quality and performance improvement; b. Supporting a culture of quality improvement within the governing body and at the public health agency; c. Holding governing body members and the health director/health officer to high performance standards and evaluating their effectiveness; d. Examining structure, compensation, and core functions and roles of the governing body and the public health agency on a regular basis; and e. Providing orientation and ongoing professional development for governing body members. 6. Oversight: Assume ultimate responsibility for public health performance in the community by providing necessary leadership and guidance in order to support the public health agency in achieving measurable outcomes. These may include, but are not limited to: a. Assuming individual responsibility, as members of the governing body, for 2|Management Operations – Board of Health: Overall Operations

Appalachian District Health Department

Policy and Procedure Policy Name Section 200 Approved Date: BOH 3-8-08 Management Operations Policy Topic Chapter 223 Revised Date: 2-16-13 9-12-17 Board of Health: Overall Operations actively participating in governing entity activities to fulfill the core functions; b. Evaluating professional competencies and job descriptions of the health director/health officer to ensure that mandates are being met and quality services are being provided for fair compensation; c. Maintaining a good relationship with health director/health officer in a culture of mutual trust to ensure that public health rules are administered/enforced appropriately; d. Hiring and regularly evaluating the performance of the health director; and e. Acting as a go-between for the public health agency and elected officials when appropriate. Procedures: 1. Delegation of authority to the Health Director: The Board of Health (BOH) will employ a Health Director and delegate to him/her the authority and responsibility for the overall management of the affairs of the ADHD in accordance with written policies. In the absence of written policies, the Health Director is to be guided by an application of Board intent as established in other policies and counseled where appropriate by the officers of the Board. a. The BOH will ensure that a job description for the position of the Health Director includes appropriate qualifications of education, experience and skills. b. The Health Director shall guide his/her activities by the content and spirit of the job description with duties and responsibilities outlined therein. See Attachment 1. c. The Health Director keeps the BOH updated on program events through the data and information obtained through quality improvement activities, program monitoring, internal and external (state and federal) audits and other means as available. d. The BOH will evaluate the Health Director on an annual basis. The job description will be reviewed and revised at the time of the annual review. e. The BOH is authorized to enter into a contract with any governmental or private agency or with any person for the provision or receipt of public health services. The Health Director and District Finance Officer are the authorized officials to review and approve contracts. 2. Board of Health Appointments: Appalachian District complies with NC General Statutes 130A-37: District board of health. a. Current Board of Health roster with tracking of appointment to the BOH, terms 3|Management Operations – Board of Health: Overall Operations

Appalachian District Health Department

Policy and Procedure Policy Name Section 200 Approved Date: BOH 3-8-08 Management Operations Policy Topic Chapter 223 Revised Date: 2-16-13 9-12-17 Board of Health: Overall Operations and any limitation of term positions will be the responsibility of the Health Director or designee. b. Annually or as needed, the three County Commissioner members of the Board of Health will meet to consider BOH appointments and will make such appointments based on at least two of three in agreement for each appointment. c. New BOH members will be sworn in at a regular BOH meeting. 3. Training: a. Annual training for BOH members will be provided based on collaboration and recommendations from the Health Director and/or the BOH. b. Newly appointed BOH members will be provided general board member orientation by the Health Director. c. BOH members will receive an ADHD BOH Manual and orientation material upon appointment with updates as needed. The Manual will include: i. Overview: “Introduction to Local Public Health Services in North Carolina” and ii. “Health Law” Bulletins published by the NC Institute of Government. iii. N.C. General Statutes applicable to the BOH iv. Roster of Board Members and Terms v. General Information: Strategic Plan, State of the County Health Report or Community Health Assessment Summary, Departmental Organizational Chart, ADHD Brochure of services and/or Annual Report vi. BOH Operating Procedures vii. Overall Operations Policy viii. Policy on Policies ix. Existing BOH Rules, if applicable x. Recent meeting minutes xi. Other 4. Compensation: Board members may receive a per diem in an amount established by the county commissioner members of the Board. Reimbursement for subsistence and travel shall be in accordance with District policy. 5. Legal Counsel: The BOH may request legal counsel and authorizes the Health Director to request legal counsel. This may be one of the counties’ attorneys or may be an attorney identified separately by the Health Director. a. Legal counsel may be requested for advice regarding the adoption, dissemination, evaluation, improvement and enforcement of laws, rules, regulations and polices 4|Management Operations – Board of Health: Overall Operations

Appalachian District Health Department

Policy and Procedure Policy Name Section 200 Approved Date: BOH 3-8-08 Management Operations Policy Topic Chapter 223 Revised Date: 2-16-13 9-12-17 Board of Health: Overall Operations related to ADHD public health services. b. Legal counsel will review proposed rules for compliance with local, state and federal statutes and regulations. c. Legal counsel may also be requested by the BOH or the Health Director for personnel or contractual matters. d. Legal counsel may also be sought through the North Carolina Institute for Government, the Division of Public Health or the Attorney General, especially relating to public health rules and policy. 6. Local Rules: The BOH strives to assure the promotion and protection of health and the prevention of disease of the ADHD and Alleghany, Ashe and Watauga County citizens through its adoption, dissemination, evaluation, improvement and enforcement of laws and regulations that govern the services provided. Based on information received, the BOH will evaluate the necessity of additional rules, regulations or ordinances. The BOH, Management Team and legal counsel will collaborate to establish the best alternatives and consider cost-effectiveness when making necessary additions to the rules, regulations, or ordinances. a. The BOH may adopt a more stringent rule in an area regulated by the North Carolina Commission for Public Health or the Environmental Management Commission (EMC) where, in the opinion of the BOH, a more stringent rule is required to protect the public health; otherwise, the rules of the CHS or the rules of the EMC shall prevail over local BOH rules. As provided in N.C.G.S. 130A-39, the BOH may not adopt a rule concerning the grading, operation, and permitting of food and lodging facilities as listed in Part 6 of Article 8 of Chapter 130A and as defined in N.C.G.S. 130A-335(c). b. The BOH shall follow the procedures for adopting rules outlined in N.C. G.S. 130A39. c. Rules adopted by the BOH shall apply to all municipalities within the BOH’s jurisdiction. d. When adopting, amending, or repealing any BOH rule, the following process shall occur: i. Not less than 10 days before the adoption, amendment or repeal of any BOH rule, the proposed rule shall be made available at the office of the Alleghany, Ashe and Watauga Counties’ Clerks to the Board and a notice shall be published in a newspaper having general circulation within the area of the BOH’s jurisdiction. ii. The notice shall contain a statement of the substance of the proposed rule or a description of the subjects and issues involved, the proposed effective date of the rule, and a statement that copies of the proposed rule are available at the ADHD. 5|Management Operations – Board of Health: Overall Operations

Appalachian District Health Department

Policy and Procedure Policy Name Section 200 Approved Date: BOH 3-8-08 Management Operations Policy Topic Chapter 223 Revised Date: 2-16-13 9-12-17 Board of Health: Overall Operations iii. Board rules shall become effective upon adoption unless a later effective date is specified in the rule. iv. Copies of all BOH rules shall be filed with the secretary of the BOH. v. The BOH may, in its rules, adopt by reference any code, standard, rule, or regulation which has been adopted by any agency of the state, another state, any agency of the United States or by a generally recognized association. vi. Copies of any material adopted by reference shall be filed with the rules. e. Rules Appeals Process: The BOH provides an appeals process for Alleghany, Ashe and Watauga County citizens who wish to voice concerns regarding ADHD’s interpretation or enforcement of local rules and regulations. The process will consist of the following: i. The appeals procedure shall be conducted as provided in N.C. G.S. 130A24, as described below. The appeals procedure will reflect the most current version of the relevant statute. ii. The aggrieved person shall give written notice of appeal to the ADHD within 30 days of the challenged action. The notice shall contain the name an address of the aggrieved person, a description of the challenged action and a statement of the reasons why the challenged action is incorrect. Within 5 working days upon filing of the notice, the ADHD Health Director shall transmit the notice of appeal to the BOH along with the papers and materials upon which the challenged action was taken. iii. Within 15 days of the receipt of the notice of appeal, the BOH shall hold a hearing. iv. The aggrieved person shall be given not less than 10 days notice of the date, time and place of the hearing. v. On appeal, the BOH shall have authority to affirm, modify or reverse the challenged action. The BOH’s decision shall be provided in writing based on the evidence presented at the hearing. The written decision shall contain a concise statement of the reasons for the decision. vi. A person who wishes to contest a decision of the BOH under subsection (b) of N.C.G.S. 130A-24 shall have a right of appeal to the County District Court within 30 days after the date of the decision by the BOH. The scope of review in district court shall be the same as in G.S. 150B-51. 7. Local Government Responsibilities: The BOH maintains a relationship with the county commissioners through the county commissioner member appointed to the BOH. 8. BOH Policy Development/Review/Approval: The BOH adopts and follow the ADHD Policy on Policies. 6|Management Operations – Board of Health: Overall Operations

Appalachian District Health Department

Policy and Procedure Policy Name Section 200 Approved Date: BOH 3-8-08 Management Operations Policy Topic Chapter 223 Revised Date: 2-16-13 9-12-17 Board of Health: Overall Operations 9. Strategic Planning: Strategic planning is an ongoing process at ADHD with primary responsibility resting with the Health Director, Quality Improvement Council and CORE Leadership Team. The plan is generally reviewed quarterly at Quality Council and/or CORE planning retreats and may be revised/updated at any time. The plan is reviewed and revised annually with the Board of Health after the completion of the Community Health Assessment/State of the County Health Report and Annual Reports such as Communicable Disease, Child Fatality Prevention Team and Quality Improvement. At that time, local health status data and information are used to set and/or update goals and objectives. Community input is provided through the CHA and SOTCH reports, at a minimum, but consideration is also given to Client Satisfaction Surveys, inquiries via the website or input given at meetings such as the counties’ health councils, County Planning Boards, visioning groups within the counties, Smart Start, United Way and School Health Advisory Councils. A collaborative community health approach will be used for strategic planning to ensure the ten essential functions of public health. 10. BOH Responsibilities to the Community: a. The BOH reviews reports that identify the Community’s health and needs. The State of the County Health Report or the Community Health Assessment will be reviewed to observe identified needs and to monitor the progress of direct services being provided by the ADHD in achieving positive outcomes. b. The BOH advocates for laws and regulations that better enhance and protect the health and safety of the citizens of Alleghany, Ashe and Watauga Counties. The BOH may lobby for laws and regulations that require changes. c. The BOH is actively involved in looking at the pros and cons of public health issues and potential changes, and balancing the most efficient and effective outcome. d. The BOH will also assist in ensuring that the community is given the opportunity to become aware of services, changes in services or regulations, and are given the opportunity to participate in and voice their concerns, whether positive or negative. The BOH will strive to ensure that the ADHD addresses these issues prior to making a final decision and also interacts with the community to enhance partnerships and improve agency services. e. ADHD staff may serve on community boards, committees, etc. as appropriate and with the approval of the Health Director. This is to be used as a means of developing collaboration between the ADHD and the community. f. BOH members will report to the BOH any personal or business conflict of interest that might impact his/her decisions on public health issues. Upon appointment and annually thereafter, Board members will review and complete the conflict of interest assessment and statement. See Attachment 2. g. BOH members will maintain confidentiality of information as required. Upon appointment and annually thereafter, Board members will review and sign the confidentiality statement. See Attachment 3. 7|Management Operations – Board of Health: Overall Operations

Appalachian District Health Department

Policy and Procedure Policy Name Management Operations Policy Topic Board of Health: Overall Operations

Section 200

Approved Date: BOH 3-8-08

Chapter 223

Revised Date: 2-16-13 9-12-17

11. Public Health Funding: The BOH will support the ADHD’s efforts in applying for and receiving/securing grants, diversifying funding sources and reviews, amends and approves Budget Development and Ordinances. a. An annual budget will be adopted that facilitates implementation and maintenance of the ADHD’s services. b. Preliminary budgets shall be presented for consideration at least 10 days prior to the budget adoption. c. The Health Director, or designee with delegated authority, shall serve as the Budget Officer to work with the ADHD Finance Officer for day-to-day management of adopted budget by allocated program and line item that are part of the overall budget. As such, they have the authority to make budget amendments between line items within the same program up to the amount of the adopted budget. Any budget line item amendments that would increase or decrease the overall budget or program budget require prior Board of Health approval. d. Detailed budget amendments shall be maintained by the ADHD Finance Officer and Health Director and made available to the Board of Health at any time. e. Not all services have fees associated; however, services that are chargeable are assigned a fee for service. f. Review of ADHD cost of services provided, Medicaid rates and local market rates will be among criteria that may be reviewed by the BOH in setting fees. g. The BOH will be an advocate for public health funding requirements with the Alleghany, Ashe and Watauga County Board of Commissioners, state and federal legislators.

8|Management Operations – Board of Health: Overall Operations

Attachment #1 AppHealthCare Appalachian District Health Department www.AppHealthCare.com

Caring for our Community Position:

Local Public Health Director/CEO Public Entity Federally Qualified Health Center

Location:

Appalachian District Health Department – Alleghany, Ashe and Watauga

Description of Work: Alleghany, Ashe and Watauga Counties are located in the beautiful mountains of Northwestern North Carolina with a combined population of 90,763. These three counties make up the Appalachian District Health Department.

This is a leadership position that serves as the local public health director and chief executive officer of a district health Department/public entity Federally Qualified Health Center. The position executes the power and duties as defined in NC GS 130A-41 and GS 120A-45.5 and others outlined in this position description. Position directs managers/supervisors, professional, technical and support staff in the delivery of agency services to protect and promote public health. Work involves providing leadership and directing program development and implementation, establishing program standards and monitoring and evaluating quality of service delivery systems. Position supervises budget activities and maintains direct involvement in conflict/complaint resolution, staffing and personnel issues. Position serves as the principle spokesperson for the agency relative to public health issues. Work also involves representing the agency with government officials, professional boards and associations, health care providers, public/private schools and a variety of advocacy groups to influence the decision making process in order to insure adequate resources for program maintenance and expansion and the delivery of the comprehensive services. The department currently has 86 employees with a FY 2017-18 operating budget of 8.5 million. The department currently provides the following public health services to the community: environmental health, health promotion, oral health laboratory services, communicable disease care, immunizations, Women, Infants and Children (WIC), clinical services including primary care with integrated behavioral health, dental, women’s health as well as other public health services. 1. Required Minimum Training: A master’s degree in public health administration and at least one year of employment experience in health programs or health services; or a master’s degree in public health discipline other than public health administration and at least three years of employment experience in health programs or health services; or a master’s degree in public administration and at least two years’ experience in health programs or health services; a master’s degree in a field related to public health and at least three years of experience health programs or health services; or a bachelor’s ______________________________________________________________________________________________________________________ BUSINESS OFFICE

ALLEGHANY CO. HEALTH CENTER

ASHE CO. HEALTH CENTER

WATAUGA CO. HEALTH CENTER

157 Health Services Road PO Box 309 Sparta, NC 28675 336-372-5641 336-372-7793 Fax

157 Health Services Road PO Box 309 Sparta, NC 28675 336-372-5641 336-372-7793 Fax

413 McConnell Street PO Box 208 Jefferson, NC 28640 336-246-9449 336-246-8163 Fax

126 Poplar Grove Connector PO Box 307 Boone, NC 28607 828-264-4995 828-264-4997 Fax

degree in public health administration or public administration and at least three years of experience in health programs or health services. Note: Minimum training and experience requirements are in accordance with GS 130A-40 and GS 130A-45.5. For master’s degree related to public health, the determination must be made by the State Health Director. 2. Knowledge, Skills and Abilities: Analytical ability, judgement, communication, ability to attain targets and get things done, cooperation, dependability, ability to recruit and retain good people, delegation skills, creativity, policy/management/technical knowledge, enthusiasm, ability to work under pressure.

______________________________________________________________________________________________________________________ BUSINESS OFFICE

ALLEGHANY CO. HEALTH CENTER

ASHE CO. HEALTH CENTER

WATAUGA CO. HEALTH CENTER

157 Health Services Road PO Box 309 Sparta, NC 28675 336-372-5641 336-372-7793 Fax

157 Health Services Road PO Box 309 Sparta, NC 28675 336-372-5641 336-372-7793 Fax

413 McConnell Street PO Box 208 Jefferson, NC 28640 336-246-9449 336-246-8163 Fax

126 Poplar Grove Connector PO Box 307 Boone, NC 28607 828-264-4995 828-264-4997 Fax

Attachment #2 APPALACHIAN DISTRICT BOARD OF HEALTH APPALACHIAN PARTNERS IN PUBLIC HEALTH

Conflict of Interest: Annual Statement Both boards serving Appalachian District Health Department: APPALACHIAN DISTRICT BOARD OF HEALTH (BOH) and APPALACHIAN PARTNERS IN PUBLIC HEALTH (PIPH), collectively called “Boards” throughout this document, will complete an annual disclosure statement regarding any relationship with APPALACHIAN DISTRICT HEALTH DEPARTMENT (AppHealthCare). In order to be more comprehensive, this disclosure statement also requires you to provide information with respect to certain parties that are related to you. These persons are termed “affiliated persons” and include the following: a. Your spouse, domestic partner, child, mother, father, brother or sister or spouse of a child, brother or sister; and, b. Any corporation or organization of which you are a board member, an officer, a partner, employee or participate in management or funding decisions. 1. NAME____________________________________________________ 2. Have you or any of your affiliated persons provided services or property to AppHealthCare _____YES _____NO If yes, please describe the nature of the services or property and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. Have you or any of your affiliated persons purchased services or property from AppHealthCare in the past year? _____YES _____NO If yes, please describe the purchased services or property and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. Please indicate whether you or any of your affiliated persons had any direct or indirect interest in any business transaction(s) in the past year to which AppHealthCare was or is a party? (Direct interest being a transaction or contract between AppHealthCare and you or any of your affiliated persons. An indirect interest being a transaction or contract between AppHealthCare and an entity in which you or an affiliated person has a material financial interest or is a director, officer, agent, partner, employee, trustee or other legal representative.) _____YES _____NO

If yes, describe the transaction(s) and entity and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 5. In the past year, did you or any of your affiliated persons receive, or become entitled to receive, directly or indirectly, any personal benefits from AppHealthCare or as a result of your relationship with AppHealthCare, that in the aggregate could be valued in excess of $100? _____YES _____NO If yes, please describe the benefit(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: ________________________________________________________________________ ________________________________________________________________________ 6. Are you or any of your affiliated persons a party to or have an interest in any pending legal proceedings involving AppHealthCare? _____YES _____NO If yes, please describe the proceeding(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 7. Are you aware of any other events, transactions, arrangements or other situations that have occurred or may occur in the future that you believe should be examined by AppHealthCare’s Executive/Finance Committee in accordance with the terms and intent of this Conflict of Interest Policy? _____YES _____NO If yes, please describe the situation(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ I HEREBY CONFIRM that I have read and understand AppHealthCare’s Conflict of Interest Policy and that my responses to the above questions are complete and correct to the best of my information and belief. I agree that if I become aware of any information that might indicate that this disclosure is inaccurate or that I have not complied with this Policy, I will notify the Board Chair immediately. ___________________________________ Name, please print ___________________________________ __________________ Signature Date

Attachment #3 APPALACHIAN DISTRICT BOARD OF HEALTH APPALACHIAN PARTNERS IN PUBLIC HEALTH

Confidentiality Policy for Board Members Both boards serving Appalachian District Health Department: APPALACHIAN DISTRICT BOARD OF HEALTH (BOH) and APPALACHIAN PARTNERS IN PUBLIC HEALTH (PIPH), collectively called “Boards” throughout this document, are committed to transparency in all of its undertakings and respect the professionalism of all members who serve on the Boards. The State of North Carolina mandates the BOH to operate under Open Meetings Law (§143318) and Public Records Law (§132). PIPH operates as a non-profit, and as such, is not required to operate under Open Meetings Law, but chooses open and transparent record keeping and communication. Public records is defined in §132-1(a) as “all documents, papers, letters, maps, books, photographs, films, sound recordings, magnetic or other tapes, electronic data-processing records, artifacts, or other documentary material, regardless of physical form or characteristics, made or received pursuant to law or ordinance in connection with the transaction of public business by any agency of North Carolina government or its subdivisions.” The following are not a matter of public record according to the exceptions in §132-1.1 through 132-1.11. 1. 2. 3. 4. 5.

Confidential communications by legal counsel State tax information Criminal investigations Trial preparation materials Social security numbers and other personal identifying information

The Board is committed to protect the privacy of: 1. Patients, Clients, Customers and their information 2. Staff and personnel-related issues 3. Donors and their information

I agree to uphold this policy as a Board member of: APPALACHIAN DISTRICT BOARD OF HEALTH APPALACHIAN PARTNERS IN PUBLICH HEALTH

______________________________________________________________________ Signature Date __________________________________________________ (Board member name, printed)