Form no number no number NBCCEDP Cost Assessment Tool

NBCCEDP Cost Assessment Tool and User’s Manual

Form Approved

OMB No. 0920-xxxx
Exp. Date: xx/xx/20xx

NBCCEDP Cost Assessment Tool

Centers for Disease Control and Prevention

National Center for Chronic Disease Prevention and Health Promotion

Division of Cancer Prevention and Control

Buford Highway, MS K-55

Atlanta, GA 30341

Phone: (770) 488-3182

FAX (770) 488-4639

E-mail: [email protected]

Public reporting burden of this collection of information is estimated to average 22 hours per program, 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). Do not send the completed form to this address.

1. GRANTEE DETAILS
	1A. Grantee name
	1B. Primary contact person
	Telephone
	Email
	1C. Please indicate program delivery structure (consult User's Guide)

	1D Please indicate "yes" or "no" for the questions below:
	Do you provide any clinical services (e.g., pap smears) in satellite offices?
	Do you have contracts with physician offices to provide screening services?
	Do you have contracts with local/regional health department, private hospitals or other entities to provide screening services?
	Where is case management performed (please indicate all that apply)?
		Grantee - Central Office
		Grantee - Satellite Office
		Physician Office
		Contractor (provider)*

	Where is tracking and follow-up services performed (please indicate all that apply)?
			Grantee - Central Office
			Grantee - Satellite Office
			Physician Office
			Contractor (provider)*
	Who performs data entry (please indicate all that apply)?
			Grantee
			Physician Office
			Contractor (provider)*

	Who performs data analysis (please indicate all that apply)?
			Grantee
			Physician Office
			Contractor (provider)*
	Who handles billing and reimbursement (please indicate all that apply)?
			Grantee
			Physician Office
			Contractor (provider)*
			Contractor (non-provider)
	Who performs public education and outreach activities (please indicate all that apply)?
		Grantee assess and sets priorities
		Contractor assess and sets priorities
		Grantee performs the activities
		Contractor performs the activities
	1E Please provide a description of your program delivery structure below:

* includes local/regional health department, private hospital and other entities who provide screening and diagnostic services

2. TOTAL EXPENDITURE
2A. Federal Funds (please indicate)
Type of federal fund	$Amount
Total federal funding for current year
Unobligated federal funds carried forward from previous year
Amount of federal funds unspent for the current year
Total federal funds expended:	#VALUE!

2B. Non-Federal Funds (please indicate; use additional rows to indicate other sources)

Source of non-federal fund	$ Amount	Activity (if applicable)	Comments
American Cancer Society (ACS)
Avon Foundation grant
Susan G. Komen Foundation grant
State funds
Total non-federal funds expended: $	-
Total expenditure $	-

3. IN-KIND CONTRIBUTIONS

3A. Assistance from Hospitals and Physicians

Have participants in your program received in-kind services through voluntary services provided by physicians or hospitals?
If yes, please explain:

3B. In-Kind Contributions--Labor

Source of in-kind contributions	$ Amount	Activity (if applicable)	Method used to estimate $ value	Other Methods/Comments
Division Chief – Department of Health	$3,000	Management	Percentage of staff salary
Physician – Scientific Advisory Board	$900	Quality Assurance	Other	Estimate (based on hourly rate of $150)
Total:	-

3C. In-Kind Contributions--Non Labor (e.g., materials, equipment etc.)

Source of in-kind contributions	$ Amount	Activity (if applicable)	Method used to estimate $ value	Other Methods/Comments
Computer and other electronics	$1,500		Market Price
Total:	-

Total in-kind contributions $

-

4. PERSONNEL EXPENDITURE
	Job Title	FTE % (a full-time employee is 100%)	Number of hours worked per week	Salary (based on annual time worked on all activities)			% Time spent on NBCCEDP activities	Salary allocated to NBCCEDP activities	Activity 1	% Time Activity 1	Activity 2	% Time Activity 2	Activity 3	% Time Activity 3
				Base	Fringe	Total
ex 1	Program Director	100%	40	70,000	10,000	80,000	10%	8,000	Manage-ment	100%
ex 2	Public Health Nurse	50%	20	25,000	5,000	30,000	100%	30,000	Public Education	50%	Case Management	50%
1								-
2						-		-
3						-		-
4						-		-
5						-		-
6						-		-
7						-		-
8						-		-
9						-		-
10						-		-
11						-		-
12						-		-
13						-		-
14						-		-
15						-		-
						Total staff cost:		-

5. CONSULTANT EXPENDITURE
		Job Title	Annual Payment	Activity 1	% Time Activity 1		Activity 2	% Time Activity 2	Activity 3	% Time Activity 3
ex 1		Outreach Specialist	$30,000	Patient Support	100%
ex 2		Public Health Nurse	$60,000	Case Management	70%		Professional Education	30%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
	Total cost of consultants:		-

6. SCREENING COSTS
6A. Indicate the type of screening procedures that you offer (apart from the usual mammograms, CBEs and Pap tests):
Breast Cancer Screening
Digital mammography
Other tests, please specify below:
Cervical Cancer Screening
Liquid based cytology
HPV testing
Other tests, please specify below:

		$ Amount
6B. Cost associated with specific tests:
Test		Cost
Breast cancer screening
Mammogram
Breast cancer diagnostic procedures
Diagnostic Mammogram
Ultrasound
Fine Needle Aspiration (FNA)
Non-excisional Biopsy
Excisional biopsy
Surgical consult
Anesthesia services
Facility Services
Pathology-breast
Other specify here:
Cervical cancer screening
Pap test
HPV testing

Cervical cancer diagnostic procedures
Colpo-directed biopsy
Colposcopy alone
Loop Electrode Excision Procedure (LEEP)
Diagnostic Conization
Endocervical Curretage
Anesthesia services
Facility Services
Pathology- cervical
Other specify here:
6C. Cost of breast cancer screening/diagnosis without office visit:
Screening only		-
Diagnosis only		-
6D. Cost of cervical cancer screening/diagnosis without office visit:
Screening only		-
Diagnosis only		-

6E. Cost of office visit:
6F. Total cost of screening and diagnosis		-
6G. Please indicate cost of providing transportation for clients to receive screening or diagnostic services

7. FUNDING FOR NON-SCREENING ACTIVITIES PERFORMED BY HEALTH DEPARTMENTS/CENTERS OR PROVIDERS

Provider Activities	$ Amount
Administration/site coordination
Data collection and management
Case management
Outreach
Public education
Professional education
Total	-

8. COSTS ASSOCIATED WITH CONTRACTS, MATERIALS, TRAVEL, AND SERVICES
	Description	Amount of Contract ($)	Cost Calculation	NBCCEDP Activity (if appropriate)
ex 1	Software upgrade	$10,000	Actual	n/a
ex 2	Third-party payer	$100,000	Actual	Screening
ex 3		$5,000	Actual	Outreach
ex 4		$10,000	Estimate	Professional education
1
2
3
4
5
6
7
8
9
10
	Total cost of significant materials, supplies, and activities	-

9. ADMINISTRATIVE COSTS
9A. Allocation methodology		Y/N	% Amount
Fixed dollar amount
Allocated as a percent of direct cost (indicate %)
Other: (Specify)
9B. Total program administrative or overhead costs (please indicate amount paid)
9C. 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

10. ALLOCATION OF RESOURCES TO BREAST VS. CERVICAL SCREENING
Program Activities	Percentage allotted for Cervical Cancer Screening	Percentage allotted for Breast Cancer Screening
Case management/Patient support		100
Professional education		100
Public education		100
Outreach		100
Partnerships		100
Quality assurance		100

Instructions and Technical Specifications

Drop Down Box Categories
Program components/activities:
Program Management
Screening & Diagnostic Services
Patient Support/Case Management
Data management
Tracking and Follow-up
Quality Assurance/Quality Improvement
Partnerships
Professional Development
Recruitment-60%
Recruitment-40%
Evaluation
N/A	ONLY FOR #8
Source of Non-Federal Funds:
American Cancer Society (ACS)
State funds
Susan G. Komen Foundation grant
Avon Foundation grant
In-Kind--Labor:
IT Support
Other Staff Time (Supervisors, Administrative Staff etc.)
Provider Services
In-Kind-- Non Labor:
Computer and Other Electronics
Furniture
Office Supplies
Value Estimation Method for In-Kind Contribution:
Differential b/w charges and Market Price
Differential b/w charges and Medicare rates
Percentage of Staff Salary
Market Price
Other
Job Titles:
Administrative Assistant
Clinical Nurse Specialist
Data Manager
Info Tech Specialist
Program Director
Program Manager
Public Health Nurse
Services Coordinator
Statistician
Student Worker
Other
Consultants:
Outreach Specialist
Public Health Nurse
Social Worker
Co-ordinator
Media/marketing Specialist
Info Tech Specialist
Other
Grantee Program Structure:
Centralized
Mixed
De-centralized
Grantees:
Alabama
Alaska
American Samoa
Arctic Slope Native Association Limited
Arizona
Arkansas
California
Colorado
Connecticut
Cherokee Nation
Cheyenne River Sioux Tribe
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Hopi Tribe
Idaho
Illinois
Indiana
Iowa
Kansas
Kaw Nation of Oklahoma
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Mississippi Band of Choctaw Indians
Missouri
Montana
Native American Rehabilitation Association of the Northwest, Inc.
Navajo Nation
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Poarch Band of Creek Indians
Puerto Rico
Republic of Palau
Rhode Island
South Carolina
South Dakota
South East Alaska Regional Health Consortium
South Puget Intertribal Planning Agency
Southcentral Foundation
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon-Kuskokwim Health Consortium
dichotomous responses	Color Coding in the Cost Assessment Tool
Yes		Do not enter any values or text here
No		Select from drop down boxes
		Enter values or text here
		These are examples

Form Approved

OMB No. 0920-xxxx
Exp. Date: xx/xx/20xx

Cost Assessment Tool (CAT)

User’s Manual

Public reporting burden of this collection of information is estimated to average 22 hours per program, 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). Do not send the completed form to this address.

INTRODUCTION

This instruction manual has been prepared to assist NBCCEDP grantees to provide the information requested in the Cost Assessment Tool (CAT) questionnaire. The CAT is used to collect information on cost data elements and also allocate these costs to specific activities performed by grantees. This data collection effort will provide CDC with activity-based cost elements to understand the cost of the various activities performed by the NBCCEDP grantees, the factors that may impact these costs, and the cost-effectiveness of the programs. Based on these analyses, CDC can utilize a systematic process to allocate program funds based on grantees’ past performance and future needs. The cost data collected will also be used by the grantees themselves to improve efficiencies within their programs.

The information collected in the CAT consists of a set of standardized cost data elements developed to ensure that consistent and complete information on annual expenditures, in-kind contribution, staff and consultant salaries, screening costs, contracts and material costs, provider payments, administrative costs, and allocation of funds and staff time to breast cancer versus cervical cancer screenings are collected on all NBCCEDP grantees. Since the objective of the cost data collection is to collect activity based cost data, information on cost incurred or expenditures should be reported and not budget data. For example, budget data is the amount anticipated to be spent on screening services (as calculated in the Clinical Cost Worksheet), whereas the CAT will collect the actual amount spent on screening based on amount reimbursed to providers.

The data is collected via the web to reduce respondent burden, data collection errors and delays in receiving data. The web-based tool includes several features to specifically reduce burden and collect high quality data. For example, the tool contains automated data checks so that the grantees can perform self-directed quality checks on the data as they input it. In addition, the list of NBCCEDP activities is provided in drop-down boxes to eliminate the time spent typing in text and the tool also contains an interactive user’s guide that provides variable definitions and instructions for providing the required data elements.

This manual was written by RTI International, under the Centers for Disease Control and Prevention (CDC) Contract No. 200-2002-00575, Task Order No. 0006 (Economic Analysis of the NBCCEDP OBM # 0920-XXXX, expiration date XX/XX/20XX).

Guidelines to Complete the Questionnaire

General Instructions: Please enter values and text in cells highlighted in blue. The cells highlighted in green have drop down boxes with several choices to select from. Please do not enter any information in the yellow cells as the information in these cells is calculated automatically based on predetermined formulae.

Color Coding in the Cost Assessment Tool
	Do not enter any values or text here
	Select from drop down boxes
	Enter values or text here
	These are examples

Specific goals of the NBCCEDP Data User’s Manual are to:

• Provide technical information necessary to complete the cost data questionnaire.

• Provide conventions to use in preparing the data.

• Provide guidelines for ensuring data quality.

• Provide examples of the data entry forms.

• Provide technical assistance to the grantees.

Data coordinators for each grantee will use the NBCCEDP Data User’s Manual as they collect and prepare the data for submission to RTI. Please report cost data for the 2007 fiscal year (July 1, 2006 to June 31, 2007). Files containing cost data will be submitted to RTI by July 31, 2008. This is a one-time effort to collect annual data from all 68 grantees.

1. GRANTEE DETAILS

Grantee Details Screen

1A. Grantee name
1B. Primary contact person
Telephone
Email
1C. Please indicate program delivery structure (consult User's Guide)
1D Please indicate "yes" or "no" for the questions below:
Do you provide any clinical services (e.g., pap smears) in satellite offices?
Do you have contracts with physician offices to provide screening services?
Do you have contracts with local/regional health department, private hospitals or other entities to provide screening services?
Where is case management performed (please indicate all that apply)?
		Grantee - Central Office
		Grantee - Satellite Office
		Physician Office
		Contractor (provider)*
* includes local/regional health department, private hospital and other entities who provide screening and diagnostic services
Where is tracking and follow-up services performed (please indicate all that apply)?
		Grantee - Central Office
		Grantee - Satellite Office
		Physician Office
		Contractor (provider)*
Who performs data entry (please indicate all that apply)?
		Grantee
		Physician Office
		Contractor (provider)*
Who performs data analysis (please indicate all that apply)?
		Grantee
		Physician Office
		Contractor (provider)*

Who handles billing and reimbursement (please indicate all that apply)?
		Grantee
		Physician Office
		Contractor (provider)*
		Contractor (non-provider)

Who performs public education and outreach activities (please indicate all that apply)?
		Grantee assess and sets priorities
		Contractor assess and sets priorities
		Grantee performs the activities
		Contractor performs the activities
1E Please provide a description of your program delivery structure below:

Please select the grantee name from the drop down box under 1A. Names of all 68 grantees are provided in alphabetical order. Under 1B, please enter the primary staff contact information. This person will be contacted if there are any questions regarding the data elements provided.

Under 1C, please enter the type of service delivery system. Please refer to the definitions of the service delivery system below before making the selection.

I. Centralized program structure: grantee provides clinical services in its satellite offices (may exclude mammograms and diagnostics), pays the salary of clinicians who provide services in various locations by arrangement, performs all tracking and follow-up services, provides all case management (CM) services, performs all data entry and analysis, performs all billing and reimbursement services, and performs all public education and outreach activities.

II. Mixed program structure: grantee contracts directly with physician offices for all clinical services, contracts directly with physician offices to perform tracking and follow-up services, and to provide all CM services. Contractor(s) enter data in database, and grantee runs reports/conducts analysis. Hired contractor performs all billing and reimbursement services. Grantee assesses public education and outreach needs, develops messages and sets priorities, and contractors deliver public education and outreach.

III. De-centralized program structure: grantee contracts with local/regional health departments, private hospitals or other entities to fully manage and subcontract screening and diagnostic services, perform and/or subcontract tracking & follow-up services, to provide and/or subcontract CM services, and perform billing and reimbursement services. Contractors collect, enter and analyze data, assess public education and outreach needs, set priorities and provide public education and outreach.

For questions under 1D, indicate ‘yes’ or ‘no’ for each. Please indicate ‘yes’ for all categories that apply for each question. The responses to these questions will be reviewed to ensure that the program delivery structure is specified consistently across all grantees.

2. TOTAL EXPENDITURE

Total Expenditure Screen

2A. Federal Funds (please indicate)
Type of federal fund	$Amount
Total federal funding for current year
Unobligated federal funds carried forward from previous year
Amount of federal funds unspent for the current year
Total federal funds expended:	#VALUE!
Source of non-federal fund	$ Amount
American Cancer Society (ACS)
Avon Foundation grant
Susan G. Komen Foundation grant
State funds
Total non-federal funds expended: $	-
Total expenditure $	-

Instructions

2

Total federal funds expended = (total federal funding for current year + unobligated federal funds carried forward from previous year) – (amount of federal funds unspent for the current year)

A. Federal Funds: Enter dollar amounts for total federal funding for current year, unobligated federal funds carried forward from previous year, and amount of federal funds unspent for the current year. ‘Total federal funds expended’ will be automatically calculated using this formula:

2B. Non-Federal Funds: Please enter the ‘source of non-federal funding’ if it is different from what the four sources listed. If you have not received funds from any of the four sources listed, please enter the amount as zero. For ‘activity’ funded by source, select from the choices in the drop down boxes in the cells highlighted in green. These activities include:

Program Management

Screening & Diagnostic Services

Patient Support/Case Management (activities with direct patient contact)

Data management

Client Tracking

Quality Assurance/Quality Improvement

Partnerships

Professional Development

Recruitment-60% (indicate all activities WITH direct client contact in this category)

Recruitment-40% (indicate activities WITHOUT direct patient contact here)

Evaluation

If you wish to add additional sources of non-federal funding you can type it in the non-highlighted cells. Total non-federal funds will be automatically summed up. The total expenditure row is also automatically calculated using the formula:

Total expenditure = total federal funds expended + total non-federal funds

CHECK POST 1: PLEASE MAKE SURE THAT YOU INPUT COST DATA
(AMOUNT SPENT IN FISCAL YEAR).

3. IN-KIND CONTRIBUTION

In-Kind Contribution Screen

3A. Assistance from Hospitals and Physicians
Have participants in your program received in-kind services through voluntary services provided by physicians or hospitals?
If yes, please explain:
3B. In-Kind Contributions--Labor
Source of in-kind contributions	$ Amount	Activity (if applicable)		Method used to estimate $ value	Other Methods/Comments
Division Chief – Department of Health	$3,000	Management		Percentage of staff salary
Physician – Scientific Advisory Board	$900	Quality Assurance		Other	Estimate (based on hourly rate of $150)
Total:	-

3C. In-Kind Contributions--Non Labor (e.g., materials, equipment etc.)

Source of in-kind contributions	$ Amount	Activity (if applicable)	Method used to estimate $ value	Other Methods/Comments
Computer and other electronics	$1,500		Market Price
Total:	-
Total in-kind contributions $	-

Instructions

3A. Please indicate if your program receives any in-kind contribution from voluntary activities performed by physicians or hospitals.

3B. In-Kind Contributions—Labor: Please choose the ‘source of in-kind contributions’, ‘activity funded by source’, and ‘method used to estimate $ value’ from the drop down boxes in the cells highlighted in green. If one funding source provided monies for more than one activity then they can be listed on multiple rows with the dollar amount relevant to specific activities. The categories for the source of in-kind contributions are:

IT Support

Other Staff Time (Supervisors, Administrative Staff etc.)

Provider Services

If you wish to add sources of in-kind contributions, you can type it in the non-highlighted cells. The choices for ‘method(s) used to estimate $ value’ are:

Market price

Differential between charges and market price

Differential between charges and Medicare rates

Percentage of staff salary

Other

An additional column is provided if you use other method(s) for calculating $ value or if you have any comments. The totals will be calculated automatically. The choices for program activities remain the same (please see the description in 2B. above).

3C. Please follow the same instructions as in 2A. The drop down categories for the source of in-kind contribution is non-labor in this case. The total in-kind contribution is calculated as follows:

Total in-kind contribution = total in-kind labor contributions + total in-kind non-labor contributions

Check Post 2: Only enter in-kind contributions that were provided or incurred during the fiscal year.

4. PERSONNEL EXPENDITURE

Personnel Expenditure Screen

	Job Title	FTE % (a full-time employee is 100%)	Number of hours worked per week	Salary (based on annual time worked on all activities)			% Time spent on NBCCEDP activities	Salary allocated to NBCCEDP activities	Activity 1	% Time Activity 1	Activity 2	% Time Activity 2	Activity 3	% Time Activity 3
				Base	Fringe	Total
ex 1	Program Director	100%	40	70,000	10,000	80,000	10%	8,000	Management	100%
ex 2	Public Health Nurse	50%	20	25,000	5,000	30,000	100%	30,000	Public Education	50%	Case Management	50%
1								-
2						-		-
3						-		-
4						-		-
5						-		-
6						-		-
7						-		-
8						-		-
9						-		-
10						-		-
11						-		-
12						-		-
13						-		-
14						-		-
15						-		-
						Total staff cost:		-

5. CONSULTANT EXPENDITURE
	Job Title	Annual Payment	Activity 1	% Time Activity 1	Activity 2	% Time Activity 2	Activity 3	% Time Activity 3
ex 1	Outreach Specialist	$30,000	Patient Support	100%
ex 2	Public Health Nurse	$60,000	Case Management	70%	Professional Education	30%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
	Total cost of consultants:	-

Instructions

Please provide information on one row for each employee in your program. Under “FTE” (Full-Time Equivalent) provide the total proportion of time employed. For example, 100% would indicate a full-time employee and any other increments less than 100% would be a part-time employee. Under the salary columns, please indicate the base and fringe salaries and the total will be calculated automatically. Under ‘% time spent on NBCCEDP activities’ indicate the proportion of time spent specifically on NBCCEDP related tasks. For example, a program director may spend 10% time on NBCCEDP activities and 90% time supervising other programs. Example 1 shows the appropriate way of indicating this. In the activities column, please indicate up to three main activities performed within the NBCCEDP by the staff member and the percent of total time spent on each. If an individual performs less than three activities, please leave unneeded columns blank. The percent time spent on all three activities should equal 100%.

Please enter the appropriate job-title for the staff member. The choices in the drop down categories are:

Administrative Assistant

Clinical Nurse Specialist

Data Manager

Info Tech Specialist

Program Director

Program Manager

Public Health Nurse

Services Coordinator

Statistician

Student Worker

Other

T

Check Post 3: Please make sure salaries entered in the questionnaire are the full annual salaries earned by staff members and not only the amounts related to NBCCEDP activities.

he choices for program activities remain the same (please see the description in 2B. above).

5. CONSULTANT EXPENDITURE

Consultant Expenditure Screen

	Job Title	Annual Payment	Activity 1	% Time Activity 1	Activity 2	% Time Activity 2	Activity 3	% Time Activity 3
ex 1	Outreach Specialist	$30,000	Patient Support	100%
ex 2	Public Health Nurse	$60,000	Case Management	70%	Professional Education	30%
1
2
3
		Total cost of consultants:		-

Instructions

Please complete one line in the chart for each consultant to your program. Similar to personnel expenditure, in the activities column, please indicate up to three main activities performed for the NBCCEDP by the consultant and the percent of total time spent on each. If an individual performs less than three activities, please leave unneeded columns blank. The percent time spent on all three activities should equal 100%.

Please enter the job titles for the consultant from the categories provided in the drop down box:

Outreach Specialist

Public Health Nurse

Social Worker

Coordinator

Media/marketing Specialist

Info Tech Specialist

Other

The choices for program activities remain the same (please see the description in 2B. above).

Check Post 4: Only payments made for services incurred during the fiscal year should be reported.

6. SCREENING COSTS

Screening Cost Screen

6A. Indicate the type of screening procedures that you offer (apart from the usual mammograms, CBEs and Pap smears):
Breast Cancer Screening
Digital mammography
Other tests, please specify below:
Cervical Cancer Screening
Liquid based cytology
HPV testing
Other tests, please specify below:
		$ Amount
6B. Cost associated with specific tests:
Test		Cost
Breast cancer screening
Mammogram
Breast cancer diagnostic procedures
Diagnostic Mammogram
Ultrasound
Fine Needle Aspiration (FNA)
Non-excisional Biopsy
Excisional biopsy
Surgical consult
Anesthesia services
Facility Services
Pathology-breast
Other specify here:
Cervical cancer screening
Pap smear
HPV testing
Cervical cancer diagnostic procedures
Colpo-directed biopsy
Colposcopy alone
Loop Electrode Excision Procedure (LEEP)
Diagnostic Conization
Endocervical Curretage
Anesthesia services
Facility Services
Pathology- cervical
Other specify here:
6C. Cost of breast cancer screening/diagnosis without office visit:
Screening only		-
Diagnosis only		-
6D. Cost of cervical cancer screening/diagnosis without office visit:
Screening only		-
Diagnosis only		-
6E. Cost of office visit:
6F. Total cost of screening and diagnosis		-
6G. Please indicate cost of providing transportation for clients to receive screening or diagnostic services

Instructions

Please provide details on the cost associated with screening and follow-up diagnostic tests. Under 6A, please indicate if you offer the screening procedures listed. Under 6B, enter costs associated with the specific tests without the cost of office visits. Similarly under 6C and 6D, insert breast and cervical screening and diagnostic costs without cost of office visits. The total screening and diagnostic tests cost without office visit cost will be automatically calculated in the cell highlighted in yellow. Please specify the cost for office visits in a separate category under 6D.

7. FUNDING FOR NON-SCREENING ACTIVITIES PERFORMED BY HEALTH DEPARTMENTS/CENTERS OR PROVIDERS

Non-Screening Activities Performed by Health Departments/Centers or Providers Screen

Provider Activities	$ Amount
Administration/site coordination
Data collection and management
Case management
Outreach
Public education
Professional education
Total	-

Instructions

This section needs to be completed by decentralized and mixed programs that provide funds to health departments or providers to perform activities other than screening and diagnostic services. These activities could include administration/site coordination, data collection and management, case management, outreach, public education, professional education, and transportation. Please estimate the funds provided and expended on specific activities by the providers.

8. COSTS ASSOCIATED WITH CONTRACTS, MATERIALS AND SERVICES

Contracts, Materials and Services Screen

	Description	Amount of Contract ($)	Cost Calculation	NBCCEDP Activity (if appropriate)
ex 1	Software upgrade	$10,000	Actual	n/a
ex 2	Third-party payer	$100,000	Actual	Screening
ex 3		$5,000	Actual	Outreach
ex 4		$10,000	Estimate	Professional education
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2
3
	Total cost of significant materials, supplies, and activities	-

Instructions

In this table, please use one row to report each contract or material purchased that was $5,000 or more. You can also include group of related contracts or materials purchased if they totaled $5,000 or more. For example, printing materials for multiple public health education campaigns that combined together totaled more than $5,000 but not each individually. If applicable, please indicate the program activity that the contracted service or material corresponds to and report whether ‘actual’ or ‘estimated value’ is used to estimate the cost. The choices for program activities remain the same (please see the description in 2B. above).

9. ADMINISTRATIVE COSTS

Administrative Costs Screen

9A. Allocation methodology		Y/N	% Amount
Fixed dollar amount
Allocated as a percent of direct cost (indicate %)
Other: (Specify)
9B. Total program administrative or overhead costs (please indicate amount paid)

9C. 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

Instructions

Under 9 A, provide allocation method used for administrative costs. Examples of allocation methods include ‘fixed dollar amount’ and ‘allocation of percent of direct costs.’ Under 9 B, provide details on whether costs associated with rent , repairs/maintenance, network connection/maintenance, phone service, and shared office equipment, are included in overall administrative cost. If these are paid for as specific line item charges please provide the dollar amounts.

10. ALLOCATION OF RESOURCES TO BREAST VS. CERVICAL SCREENING

Allocation of Resources to Breast vs. Cervical Screening Screen

Program Activities	Percentage allotted for Cervical Cancer Screening	Percentage allotted for Breast Cancer Screening
Case management/Patient support		100
Professional education		100
Public education		100
Outreach		100
Partnerships		100
Quality assurance		100

Instructions

This information is requested to allocate cost of specific NBCCEDP activities appropriately to breast and cervical cancer screening. This information is required to assess the average cost of breast cancer screening and average cost of cervical cancer screening separately. Enter the proportion of resources allotted to breast cancer screenings and the proportion allotted to cervical cancer screenings will be automatically calculated using the formula given below.

Percentage of resources allotted to cervical cancer screening = 100- (Percentage of resources allotted to breast cancer screening)

Check Post 5: Please make sure that the proportion of resources devoted to Breast Cancer is ≤ ‘100%’

Thanks for completing this questionnaire.

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