Cost Assessment of AoA-funded Fall Prevention Programs

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Overview

Attachment 3
OMB Burden Box
Cover
Instructions
Participant Info
A-Program Questions
B-Cost Category Definitions
C-One-Time Costs
D.1-Recurring Costs
E-One-Time Costs (SAMPLE)
E-Recurring Costs (SAMPLE)

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Sheet 1: Attachment 3

Attachment 3 Cost Assessment for AOA-Funded Fall Programs

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Sheet 2: OMB Burden Box

Form Approved
OMB Control No. 0920-0818
Expiration Date: 07/31/2010

Public reporting burden for this collection of information is estimated to average 2 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0818).

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Sheet 3: Cover

	Cost Assessment for AOA-Funded
	Fall Prevention Programs

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Sheet 4: Instructions

Instructions
Program Name:
Location:
Instructions: The attached workbook pages are cost collection survey. Please review the instructions below to complete these cost collection survey for your Program. A sample survey is also included for your review. When you have completed this survey, please send it electronically to (INSERT CONTACT E_MAIL) or via facsimile to (INSERT FAX NUMBER) no later than (INSERT DUE DATE).
Participant Information
Please provide your contact information in the event we need to reach out to you for any clarification or follow-up information.
Section A: Program Information
Please provide short responses to the questions on Tab "A-Program Questions", relating to the implementation, management, and oversight of your Program.
Section B: Cost Category Definitions
This section is a reference page that includes a detailed description of each of the cost categories being sought. We recommend that you review these cost definitions before attempting to complete this survey.
Section C: One-Time Costs
One-time costs are also considered the investment costs to acquire and implement a selected program. This includes things such as purchase of equipment, initial instructor training, and other one-time costs to implement the program. In worksheet "C One-Time Costs", please provide as much detail as possible on any given cost category.
If you are uncertain as to which category a specific cost applies, or the category is not clearly defined, then please place that cost information under 1.3.1 Other Costs and provide as much detail as possible in the description. If you are uncertain as to the exact costs something may have cost (or will cost), please provide your own estimated range of costs, and provide any assumptions in the Notes column provided. If any cost category does not apply, please enter "N/A".
Section D: Recurring Costs
These costs are considered the routine operational costs to maintain a Program once it is implemented. This includes recurring costs, such as trainer/coach salary costs, manual reproduction costs, facility space rental costs, etc. In worksheet "D Recurring Costs", please provide as much detail as possible on any given cost category. If you are uncertain as to how to classify a specific cost, please enter your information under "2.6 Other Recurring Costs" and provide as much detail as possible in the description. If you are uncertain as to the exact costs, please provide your own estimated range of costs, with any assumptions provided in the Notes column provided. If any cost category does not apply, please enter "N/A".
For trainer/coaching costs, it is important to capture the total labor costs associated with trainer and coaching services. This should include the total labor costs, comprised of salary and benefits. If the trainers to your Program are volunteers and do not receive any salary/ wages, please indicate "volunteer" in the description.
Section E: Samples
To assist you in collecting data and populating this template, a completed sample is provided in this section. This sample includes the One-Time Costs worksheet and the Recurring Costs worksheets. Please use this sample as a reference tool with regards to the level of detail requested.
If during the process you have any questions or need further clarification on these instructions, please feel free to contact us at (INSERT CONTACT INFORMATION). On behalf of the CDC-Falls Prevention Program, thank you for your time and assistance.

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Sheet 5: Participant Info

Please provide the following information before completing this template.
Name
Contact Phone No.
E-mail:
Program Name
Address
State

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Sheet 6: A-Program Questions

Section A: Program Questions
Program:	-
Instructions
Please provide a short narrative response to the following questions as they relate to the management and oversight of your Program. This information will help us better understand the financial impacts of implementing and maintaining a similar program.
Question 1: How would you describe the turn-over for instructors/ leaders/coaches for your program? Would you characterize it as frequent or infrequent?
Question 2: As a follow-up to Question 1, does your trainer/instructor turn-over impact the frequency you need to train or retrain instructors?
Question 3: Please describe the equipment typically used for your program (i.e., resistance bands, yoga mats, etc.)
Question 4: Does your program furnish all equipment for the participants? If not, what do you provide and what is the participant expected to bring?
Question 5: How much time does it normally take to train a new instructor?
Question 6: Do you offer your existing instructors/ leaders refresher training? If so, how frequently?
Question 7: What would you describe as the greatest challenge in implementing your program?
Question 8: What would you describe as the greatest challening in maintaining your program?
Question 9: Do you conduct your program in partnership with another organization(s)? If so, what support do they provide (e.g., financial, staffing, facility, etc.)
Question 10: Other than partnerships stated above, are there any other organizations that provide and/or donate support (e.g., facility space, supplies, etc.)

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Sheet 7: B-Cost Category Definitions

Section B: Cost Category Definitions
Cost Element				Definition
1.0 Investment Costs
	1.1	Purchases
		1.1.1	Equiptment Purchases	This costs includes the one-time purchase cost of any equiptment used to support a given program. Examples may include, yoga mats, chairs, exercise equipment, etc.
		1.1.2	Manuals- Purchase Cost	This is the fixed costs to aquire any participant materials, such as manuals, DVDs, videos, etc.
	1.2	Staff Training
		1.2.1	Staff Training Session	This is the one-time cost to provide training services to staff that will provide the program to participants. An example of this cost would be the fee (and associated expenses) to provide an on-site coach to the train staff that will provide program services to participants (referred to as "Train the Trainer" services).
		1.2.2	Staff Training Materials	The one-time costs to provide staff with training materials, such as manuals, DVDs, videos, etc. This includes materials that are specific to a trainer, and not the materials that are acquired to provide program participants.
		1.2.3	Staff Labor Costs for Training	The labor costs associated with the time each staff is in training.
	1.3	Other One-Time Costs
		1.3.1	Other Costs	This includes any costs not captured above associated with program implementation. This may include refreshments for the Train the Trainer session and other consumables used for only the program implementation.
2.0 Operating Costs
	2.1	Staff Labor Costs		Annual loaded labor costs to provide staff (trainers) for the program. This should include actual salary costs, plus benefits, social security, and other overhead charges for labor.
	2.2	Staff Refresher Training Costs		Annual costs to conduct refresher training, or train new staff, to provide program to participants. For example, new hire training may be the same costs as initial staff training (See 1.2.1 above), whereas refresher training may be purchasing new manuals for trainers.
	2.3	Manuals Reproduction Costs		Cost to reproduce participant materials for program. This would include manual reproduction, DVD reproduction, CD-ROM reproduction costs, etc.
	2.4	Equiptment Refresh/ Upgrades		Replacement and refurbishment costs for equipment. This should include any and all refurbishment and replacement costs to support the equipment identified above in Section 1.1.1.
	2.5	Facility Costs		Costs to rent facility space to conduct class/ programs.
	2.6	Insurance/ Liability Coverage		This captures any annual insurance or liability coverage incurred to provide program services.
	2.7	Other Recurring Costs		This would include any other costs not covered by the above cost categories. An example would include refreshments served, paper products and other consumables used to support each class.

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Sheet 8: C-One-Time Costs

Section C: Investment Costs for Program

-

Instructions:

One-time costs are also considered the investment costs to acquire and implement a selected program. This includes costs such as equipment and material purchases, staff training, and other one-time costs to implement the program. In this worksheet, please provide as much detail as possible on any given cost item. If you are uncertain as to how to define a certain cost, please enter your information under 1.3.1 Other Costs and provide as much detail as possible in the description. If you are uncertain as to the exact costs, please provide your own estimated range of costs, with any assumptions or caveats clearly stated in the notes section of each cost category. If any cost category does not apply, please enter "N/A".

In the event that some of these items and services are provided as part of a partnership, please indicate that those costs are covered by the partnership in the notes section below.

Investment Cost Summary

Total Cost

1.1 Purchases

These rows will automatically summarize data and information you provide below

1.1.1 Equipment Purchases

$-

1.1.2 Manual Purchase Cost

$-

1.2 One-Time Staff Costs

1.2.1 Staff Training Sessions

$-

1.2.2 Purchase of Staff Training Materials

$-

1.2.3 Cost to Train Staff (Trainers, Volunteers, Leaders, etc.)

$-

1.3 Other Investment Costs

1.3.1 Other One-Time Investment Costs

$-

Total Investment Costs

$-

1.1 Purchases

1.1.1 Equipment Purchases

Description

Quantity

Cost/ Unit

Total Cost

Notes

$-

$-

$-

$-

$-

$-

$-

Total Equipment Purchases

$-

1.1.2 Manual Purchase Cost

Description

Quantity

Cost/ Unit

Total Cost

Notes

$-

$-

$-

$-

$-

$-

$-

Total Manual Purchase Cost

$-

1.2 One-Time Staff Costs

1.2.1 Staff Training Sessions

Description

# Classes

Cost/ Class

Total Cost

Notes

$-

$-

$-

$-

$-

$-

$-

Total Staff Training Session Costs

$-

1.2.2 Purchase of Staff Training Materials

Description

Quantity

Cost/ Unit

Total Cost

Notes

$-

$-

$-

$-

$-

$-

$-

Total Staff Training Materials

$-

1.2.3 Cost to Train Staff (Trainers, Volunteers, Leaders, etc.)

Type of Training

# Staff Trained

Cost Per Staff

Total Cost

Notes

$-

$-

$-

$-

$-

$-

$-

Total Training Costs for Staff

$-

1.3 Other Investment Costs

1.3.1 Other One-Time Investment Costs

Description

Quantity

Cost/ Unit

Total Cost

Notes

$-

$-

$-

$-

$-

$-

$-

Total One-Time Investment Training Costs

$-

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Sheet 9: D.1-Recurring Costs

Section D: Recurring Costs	-
Instructions:
These costs are considered the routine operational costs to maintain a program once it is implemented. This includes cost, such as trainer salary costs, manual reproduction costs, facility space rental costs, etc. In this worksheet, please provide as much detail as possible on any given cost item. If you are uncertain as to how to define a certain cost, please enter your information under 2.6 Other Recurring Costs and provide as much detail as possible in the description. If you are uncertain as to the exact costs, please provide your own estimated range of costs, with any assumptions or caveats clearly stated in the notes section of each cost category. If any cost category does not apply, please enter "N/A".
In the event that some of these items and services are provided as part of a partnership, please indicate that those costs are covered by the partnership in the notes section below.
Recurring Cost Summary			Annual Cost
2.1 Staff Labor Costs			$-	These rows will automatically summarize data and information you provide below
2.2 Staff Refresher Training Costs			$-
2.3 Manuals Reproduction Costs			$-
2.4 Equipment Refresh/ Upgrades			$-
2.5 Facility Costs			$-
2.6 Insurance/ Liability Coverage			$-
2.7 Other Recurring Costs			$-
Total Annual Costs			$-
2.1 Staff Labor Costs
Staff Type/ Position	#	Salary/Benefits	Annual Cost	Notes
			$-
			$-
			$-
			$-
			$-
			$-
			$-
Annual Staff Labor Costs	-		$-
2.2 Staff Refresher Training Costs
Description	# Staff	Cost/ Staff	Annual Cost	Notes
			$-
			$-
			$-
			$-
			$-
			$-
			$-
Annual Staff Refresher Training Costs	-		$-
2.3 Manuals Reproduction Costs
Description	Quantity	Cost/ Unit	Annual Cost	Notes
			$-
			$-
			$-
			$-
			$-
			$-
			$-
Annual Manuals Reproduction Costs	-		$-
2.4 Equipment Refresh/ Upgrades
Description	Quantity	Cost/ Unit	Annual Cost	Notes
			$-
			$-
			$-
			$-
			$-
			$-
			$-
Annual Equipment Refresh/ Upgrades	-		$-
2.5 Facility Costs
Description	Units	Cost/ Unit	Annual Cost	Notes
			$-
			$-
			$-
			$-
			$-
			$-
			$-
Annual Facility Costs	-		$-
2.6 Insurance/ Liability Coverage
Description	Quantity	Cost/Unit	Annual Cost	Notes
			$-
			$-
			$-
			$-
			$-
			$-
			$-
Annual Insurance/Liability Coverage	-		$-
2.7 Other Recurring Costs
Description	Cost/ Week		Annual Cost	Notes
			$-
			$-
			$-
			$-
			$-
			$-
			$-
Annual Other Recurring Costs	$-		$-

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Sheet 10: E-One-Time Costs (SAMPLE)

Section C: Investment Costs for Program: EXAMPLE
Investment Cost Summary (EXAMPLE)			Total Cost
1.1 Purchases				These rows will automatically summarize data and information you provide below
1.1.1 Equipment Purchases			$839.50
1.1.2 Manual Purchase Cost			$125.00
1.2 One-Time Staff Costs
1.2.1 Staff Training Sessions			$750.00
1.2.2 Purchase of Staff Training Materials			$1,575.00
1.2.3 Cost to Train Staff (Trainers, Volunteers, Leaders, etc.)			$1,200.00
1.3 Other Investment Costs
1.3.1 Other One-Time Investment Costs			$84.00
Total Investment Costs			$4,573.50
1.1 Purchases
1.1.1 Equipment Purchases
Description	Quantity	Cost/ Unit	Total Cost	Notes
Yoga mats	20.00	$15.00	$300.00
Towels	50.00	$6.99	$349.50
Elastic retention bands (set of 5 bands)	20.00	$9.50	$190.00
Total Equipment Purchases			$839.50
1.1.2 Manual Purchase Cost
Description	Quantity	Cost/ Unit	Total Cost	Notes
DVD-Yoga and Balance	5.00	$25.00	$125.00
			$-
			$-
Total Manual Purchase Cost			$125.00
1.2 One-Time Staff Costs
1.2.1 Staff Training Sessions
Description	# Classes	Cost/ Class	Total Cost	Notes
Train the Trainer Class (5 trainers/ class)	2	$250.00	$500.00
Advanced Class (5 trainers/ class)	1	$250.00	$250.00
Total Staff Training Session Costs			$750.00
1.2.2 Purchase of Staff Training Materials
Description	Quantity	Cost/ Unit	Total Cost	Notes
Manuals- basic	7	$100.00	$700.00
Manuals- advance class	7	$125.00	$875.00
			$-
Total Staff Training Materials			$1,575.00
1.2.3 Cost to Train Staff (Trainers, Volunteers, Leaders, etc.)
Type of Training	# Staff Trained	Cost Per Staff	Total Cost	Notes
Basic class (8hrs/class)	10	$80.00	$800.00
Advanced class (8 hrs/class)	5	$80.00	$400.00
			$-
			$-
Total Training Costs for Staff			$1,200.00
1.3 Other Investment Costs
1.3.1 Other One-Time Investment Costs
Description	Quantity	Cost/ Unit	Total Cost	Notes
Refeshments during staff training (3 classes)	3	$30.00	$33.00
Flyers for program	50	$1.00	$51.00
			$-
Total One-Time Investment Training Costs			$84.00

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Sheet 11: E-Recurring Costs (SAMPLE)

Section D: Recurring Costs: EXAMPLE
Recurring Cost Summary (EXAMPLE)			Annual Costs
2.1 Staff Labor Costs*			$131,000	These rows will automatically summarize data and information you provide below
2.2 Staff Refresher Training Costs			$1,200
2.3 Manuals Reproduction Costs			$1,000
2.4 Equipment Refresh/ Upgrades			$185
2.5 Facility Costs			$2,240
2.6 Insurance/ Liability Coverage			$-
2.7 Other Recurring Costs			$2,600
Total Annual Costs			$138,225
2.1 Staff Labor Costs*
Staff Type/ Position	# Staff	Salary/Benefits	Annual Cost	Notes
Full-time trainers/ coaches	2.00	$18,000.00	$36,000
Advanced trainers- part-time services	2.50	$24,000.00	$60,000	5 staff, part-time
Manager	1.00	$35,000.00	$35,000
			$-
			$-
			$-
			$-
Annual Staff Labor Costs			$131,000.00
2.2 Staff Refresher Training Costs
Description	# Staff	Cost/ Staff	Annual Cost	Notes
New trainers (estimated 2 new hires)	2.00	$80.00	$160.00
Refresher (estimtated for 13 existing staff)	13.00	$80.00	$1,040.00
			$-
			$-
			$-
			$-
			$-
Annual Staff Refresher Training Costs			$1,200.00
2.3 Manuals Reproduction Costs
Description	Quantity	Cost/ Unit	Annual Cost	Notes
Reproduction of DVD-Yoga and Balance	200.00	$5.00	1,000.00
Annual Manuals Reproduction Costs			$1,000.00
2.4 Equipment Refresh/ Upgrades
Description	Quantity	Cost/ Unit	Annual Cost	Notes
New yoga mats	10.00	$15.00	$150.00
New towels	5.00	$6.99	$34.95
			$-
Annual Equipment Refresh/ Upgrades	15.00		$184.95
2.5 Facility Costs
Description	Units	Cost/ Unit	Annual Cost	Notes
Rec center room rental	2	$10.00	$1,040.00	2 rooms/wk
Towel laundy services		$100.00	$1,200	$100/ mth
Annual Facility Costs			$2,240.00
2.6 Insurance/ Liability Coverage
Description	Quantity	Cost/Unit	Annual Cost	Notes
Not applicable to this program			$-
			$-
Annual Insurance/Liability Coverage Costs			$-
2.7 Other Recurring Costs
Description	Cost/ Week		Annual Cost	Notes
Refreshments for classes	$50.00		$2,600.00
Annual Other Recurring Costs			$2,600.00