Form No number No number CAT Instrument

Attachment 3a
Cost Assessment Tool

Form Approved

OMB No. 0920-XXXX

Expiration Date: XX/XX/XXXX

Public reporting burden for this collection of information is estimated to average 22 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN:PRA (0920-XXXX).

1. REGISTRY DETAILS
	1A. Registry name
	1B. Org. Type (Health Department, Contractor, Private or Other Organizational Type)
	1C. Org. Structure (Centralized or Regional)
	1D. Number of Regions (skip if Centralized)
	1E. Primary contact person
		Name
	Telephone
	E Comments: mail

2. TOTAL EXPENDITURE
2A. NPCR Funds
Type of NPCR funds	$Amount	Comments
Total NPCR federal funding for current year*
Unobligated NPCR federal funds carried forward from previous year
Amount of NPCR federal funds unspent for the current year
Total NPCR funds expended:	–
2B. Other Federal Funds
Source of other federal funds	$Amount	Comments
List other federal funds:
Total other federal funding for current year**	–
Unobligated other federal funds carried forward from previous year
Amount of other federal funds unspent for the current year
Total other federal funds expended:	–

2C. Non-Federal Funds
Source of non-federal funds	$ Amount	Activity (if applicable)	Comments
Total non-federal funds expended: $	–
Total expenditure $	–
NOTES:
* NPCR federal funds are defined as those funds that were awarded directly through the program in the 2060 program announcement.
** Sources of other federal funding include patterns of care studies, other CDC but non-NPCR funds, and any other federal funding source.
Comments:

3. IN-KIND CONTRIBUTION
3A. In-Kind Contributions--Labor
Source of in-kind contributions (labor)	$ Amount	Activity (if applicable)	Method used to estimate $ value	Other Methods/Comments
Legal advice received from state university	$1,000.00		Estimate
Total:	$ –

3B. In-Kind Contributions--Non Labor
Source of in-kind contributions (non-labor)	$ Amount	Activity (if applicable)	Method used to estimate $ value	Other Methods/Comments
Portion of rent contributed by state health department	$5,000		Market Value
Total:	$ –
Total in-kind contributions $	$ –
Comments:

5. PERSONNEL ACTIVITIES
Please indicate proportion of time spent on all registry activities regardless of funding source. Refer to Appendix A of user's guide for description of activities.
		Registry Director		Data Manager		0	0				0			0		0		0		0
Surveillance activities
Management (managing people)		75%
Administration (including clerical, logging, mailing, filing)
Training of registry staff
Training of others by registry staff
Database management (including system development and modification)		10%		95%
IT support
Case ascertainment (including tumor linkage and data item consolidation)
Death certificated clearance
Data collection/abstraction
Quality assurance and improvement
Developing analytic files				5%
Analyzing data and generating reports
Sharing cases
Electronic case reporting and data encryption
Reporting requirements to CDC, NAACCR, and state
		Registry Director		Data Manager		0	0				0			0		0		0		0
Data enhancement and analysis activities
Automatic casefinding using electronic linkage
Linking records to other state-wide or national databases
Geocoding cancer cases
Implementeing a cancer inquiry response system
Research studies and advanced analysis using registry data		10%
Publication of research studies using registry data		5%
Active Follow-up
TOTALS		100%	100%		0%			0%				0%			0%		0%		0%		0%
Comments:

9. ADMINISTRATIVE COSTS
9A-1. Allocation methodology I		Y/N	% Amount
Fixed dollar amount
Allocated as a percent of direct cost (indicate %)
Other: (Specify)
9A-2. Allocation methodology II		Y/N	% Amount
Fixed dollar amount
Allocated as a percent of direct cost (indicate %)
Other: (Specify)
9B. Types of costs included in the administrative or overhead costs		Y/N		$ Amount
Rent for office space			if no, provide amount
(including water, gas, electric, etc)
Repairs/maintenance			if no, provide amount
Network connection/maintenance			if no, provide amount
(i.e. internet connection charge)
Phone Service			if no, provide amount
(i.e. local phone service, long distance or cell phone charges)
Shared office equipment			if no, provide amount
Other costs:
Specify:			provide amount
Total program administrative or overhead costs
Comments:

10. OTHER FACTORS AFFECTING COSTS, EFFECTIVENESS, AND DATA COLLECTION
10A. Abstracts vs. Incidence Cases (Data consolidation effort)*	Number of Abstracts/Cases	Comments
Total number of incident cases (unique person cancer combinations)
Total number of abstracts received including non-reportable cases
CONSOLIDATION EFFORT % =	#DIV/0!
* Please report abstract and incidence cases diagnosed in 2003.
10B. Total Number of CTRs at Reporting Hospitals	Number of CTRs	Comments
Number of CTRs at Hospital sites
10C. Quality of Facility Reporting (Overall accuracy rate)	% of Facilities	Comments
Proportion of facilities passing automated edits 100%
97- 99%
90-96%
80-89%
50-79%
<50%
TOTAL % (must equal 100%) =	0%
10D. Methods of Data Reporting or Collection	% of Reports	Comments
Paper
Diskettes
Web-based
FTP
Other Electronic linkages
TOTAL % (must equal 100%) =	0%
10E. Data Collection Process	%	Comments
% of data abstracted directly from hospital records by central cancer registry staff or hired contractors.
10F. Reporting non-resident cases and data-exchange caseload	%	Comments
Collecting and reporting non-resident cases? (yes or no)
If yes, total number of cases exchanged

Comments:

Drop Down Box Categories

Registry activities:

Management

Administration

Training of registry staff

Training of others by registry staff

Database management

IT support

Case ascertainment

Death certificated clearance

Data collection/abstraction

Quality assurance and improvement

Developing analytic files

Analzying data and generating reports

Sharing cases

Reporting requirements to CDC, NAACCR, state

Electronic case reporting and data encryption

Automatic casefinding using electronic linkage

Linking records to other state-wide or national databases

Geocoding cancer cases

Implementing a cancer inquiry response system

Research studies and advanced analysis using registry data

Publication of research studies using registry data

Active follow-up

In-Kind--Labor:

IT Support

Other Staff Time (Supervisors, Administrative Staff etc.)

CTR Services

In-Kind-- Non Labor:

Computer and Other Electronics

Furniture

Office Supplies

Value Estimation Method for In-Kind Contribution:

Market value

Estimate

Other

Cost calculation method

Actual

Estimate

Other

Consultants:

Epidemiologist (masters)

Epidemiologist (Ph.D)

Statistician (masters)

Statistician (Ph.D).

Certified Tumor Registrar (CTR)

IT Specialist

Registry Program Structure:

Health Department

Private or Other Organizational Type

Health Department w/ Contractor

Registries

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Delaware

District of Columbia

Florida

Georgia

Idaho

Illinois

Indiana

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Organization Structure

Centralized

Regional

Travel Categories

Annual conferences (NAACCR/CDC meetings, etc.)

Training

Other

Fee Categories

Training

Conference

Other

Software Packages

Rocky Mountain Cancer Data System

C/NET

ELM (Premier)

CansurFacs

IMPAC

MRS

OncoLog

ERS

Other

Dichotomous Responses

yes

no

Color Coding in the Cost Assessment Tool
	Enter values or text here
	Select from drop down boxes

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