Attachment 5b Cost Assessment Tool Users Manual

ATTACHMENT 5b. Cost Assessment Tool Users Guide

Form Approved

OMB 0920-0745

Expiration Date: xx/xx/xxxx

Colorectal Cancer Control Program

Cost Assessment Tool

User’s Guide

Instructions for Program Year 2009-2010 Data Collection

Authors:

Sujha Subramanian, PhD, Project Director

Florence Tangka, PhD, Technical Monitor

Sonja Hoover, MPP

RTI International

CDC Contract No. 200-2008-27958 Task 1

March 2010

Public reporting burden of 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-24, Atlanta, GA 30333.

TABLE OF CONTENTS

INTRODUCTION 1

1. PROGRAM DETAILS 3

2. TOTAL EXPENDITURE 4

3. IN-KIND CONTRIBUTION 6

4. PERSONNEL EXPENDITURE 8

5. PERSONNEL ACTIVITIES 10

6. CONSULTANT/CONTRACT EXPENDITURE 11

7. SCREENING COSTS 12

8. CONTRACTS, TRAVEL, MATERIALS OR SERVICES PURCHASED 16

9. ADMINISTRATIVE COSTS 17

10. SUMMARY DATA SHEET 18

11. CONFIRMATION OF COST DATA 18

APPENDIX A: DESCRIPTION OF PROGRAM ACTIVITIES 19

APPENDIX B: DROP DOWN BOX CATEGORIES 21

INTRODUCTION

This manual was written to guide the Colorectal Cancer Control Program (CRCCP) grantees in completing the Cost Assessment Tool (CAT). The CAT collects information on cost data elements and allocates these costs to specific activities. This activity based data collection will allow CDC to perform in-depth evaluation of the CRCCP that has not been possible previously using budget information and federal expenditure data. Economic evaluation will provide grantees and CDC critical information to inform decision-making by assessing the effectiveness of the program in relation to the cost expended on CRCCP activities.

The information collected by the CAT consists of a set of standardized cost data elements to ensure that consistent and complete information is collected. This information consists of annual expenditures, in-kind contributions; personnel activities and expenditures; consultant expenditures; costs associated with hardware, IT support, software, and other materials; administrative costs; and other factors affecting cost, effectiveness, and data collection. These data items are the minimum necessary to evaluate the cost effectiveness of the program. The objective of the cost data collection is to collect activity based cost data. Therefore, information on actual cost incurred or expenditures should be reported and not budget data. In addition to the cost expended on specific activities, we also request information on the total funding received (from all sources). Cost data will be collected for the following periods:

Year 1: July 1, 2009 – June 30, 2010

Year 2: July 1, 2010 – June 30, 2011

Year 3: July 1, 2011 – June 30, 2012

Year 4: July 1, 2012 – June 30, 2013

Year 5: July 1, 2013 – June 30, 2014

Please note that we will also collect start-up period data. The length of the start-up period will vary for each program; however, the start-up period will occur within Year 1.

The cost data and other requested information will be collected via the web-based CAT. You will receive details on the web link, userid and password from RTI International. The CAT can be completed over several sessions by saving work in progress. Once the information for each screen is completed, grantees should save the information. ‘Save and Exit’ will save the information for the page and take the user back to the Home Page. ‘Save and Continue to Next Section’ will save the information and take the user to the next screen. Users can also skip to screens within CAT by scrolling over the CAT menu and selecting the desired screen. Information entered on a screen will not be saved unless one of the Save buttons is clicked. The sections below provide details on the screens that will have to be completed by the grantees.

Contact Information: Please contact Sujha Subramanian or Sonja Hoover from RTI, International, CDC contractor for this project, or Florence Tangka, CDC Economist, if you have any questions. You may also contact your CDC program consultant for guidance.

Sujha Subramanian, PhD

1440 Main Street, Suite 310

Waltham, Massachusetts 02451-1623

Phone: 781-434-1749

Email: [email protected]

Sonja Hoover, MPP

1440 Main Street, Suite 310

Waltham, Massachusetts 02451-1623

Phone: 781-434-1722

Email: [email protected]

Florence Tangka, Ph.D.

Division of Cancer Prevention and Control

National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)

Centers for Disease Control and Prevention (CDC)

4770 Buford Highway NE, MS K-55

Atlanta, GA 30341-3717

Phone: 770-488-1183

Email: [email protected]

1. PROGRAM DETAILS

Overview:

This worksheet collects information for each program including name and primary contact person for completing the CAT

View of Screen 1:

1A. Name
1B. Address
1C. Primary Contact Person
	Name
	Address
	Email

Instructions:

1.a. Name: From the drop down categories in the purple box, please select the awardee name.

1.b. Address: Please provide the mailing address for the program.

1.c. Primary Contact Person: Enter the name and contact information for the person whom RTI should contact if there are any questions regarding the data elements provided.

2. TOTAL EXPENDITURE

Overview:

This spreadsheet requests information regarding total funding received for CRCCP activities and includes sections for CRCCP funding and other funds.

View of Screen 2A (CRCCP funds):

Type of CRCCP funds	$ Amount	Comments
Total CRCCP funding for current year*
Unobligated CRCCP funds carried forward from previous year
Amount of CRCCP funds unspent for the current year
Total CRCCP funds expended:	—

* CRCCP funds are defined as those funds that were awarded directly by CDC through the program announcement.

View of Screen 2B (Other funds):

Source of other funds	$ Amount	Activity (if applicable)	Comments
(e.g.) CDC Comprehensive Cancer Control Program (CCCP) Funds
(e.g.) State funds
Total funds expended: $	—

Instructions:

2.a. “Federal Funds”: Enter dollar amounts of the total CDC CRCCP funding for current year and amount of CRCCP funds unspent (unobligated) for the current fiscal year. Please enter the information for unobligated funds that are reported in the annual financial status report (FSR). ‘Total CRCCP funds expended’ row will be automatically calculated using this formula:

Total CRCCP funds expended = (total CRCCP funding for current year—
amount of CRCCP funds unspent for the current year)

2.b. “Other Funds”: Please enter the ‘source of other funding’ and the ‘amount’ of funding received that support your CRCCP program for the reporting period. Please enter the sources from which you have received funding for the fiscal year. For each source of funding, select choices from the ‘CRCCP activity’ when directly applicable (that is, funding source funded one specific activity). A description for each activity category is listed in Appendix A below to assist you in completing the survey.

Total other funds expended will be automatically summed up. The total funds expended row is also automatically calculated using the formula:

Total funds expended = Total CRCCP expended + Total other funds expended

3. IN-KIND CONTRIBUTION

Overview:

This section collects information on the amount and sources of in-kind contribution that support your CRCCP program. Labor and non-labor contributions should be reported.

View of Screen 3A (Labor):

Source of In-Kind Contributions*	Hours Contributed	$ Amount	CRCCP Activity (if applicable)	Method Used to Estimate $ Value
Nurse	25	$3,000	Providing screening and diagnostic services	Percentage of staff salary
Physician - Scientific Advisory Board	6	$900	Quality Assurance	Other
Total:		—

View of Screen 3B (Non-labor):

Source of In-Kind Contributions		$ Amount	CRCCP Activity (if applicable)	Method Used to Estimate $ Value
Computer and Other Electronics		$1,500		Market Price
Total:		—

Instructions:

3.a. In-Kind Contributions—Labor: Please choose the 'source of in-kind contributions', 'activity funded by source' (please see Appendix A for details), and 'method used to assess $ value' from the drop down boxes in the cells (see Appendix B for details). An additional column is provided if you use other methods for calculating $ value or if you have any comments. 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. You can also indicate additional sources of in-kind contributions by selecting ‘other’ from ‘source of in-kind contributions’. You will be asked to specify what type of contribution if you select “other” from the drop-down menu. The totals will be calculated automatically.

3.b. In-Kind Contributions–Non-Labor: Please follow the same instructions as in 3A. The drop down categories for the source of in-kind contribution is non-labor related in this case.

The total in-kind contribution is calculated as a sum of both labor and non-labor contributions.

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

4. PERSONNEL EXPENDITURE

Overview:

This section collects information on the personnel expenditures related to CRCCP activities. Details requested include job titles, FTEs, salaries, and percentage of time spent by each staff member on CRCCP activities.

View of Screen 4:

	Job Title	FTE % (a full-time employee is 100%)	Total hours per week	Months Employed in Fiscal Year	Salary (based on annual time worked on all activities)
					Base	Fringe	Total
ex 1	Project Manager	100%	38	12	40,000	15,000	55,000
ex 2	Data Manager	50%	19	8	15,000	5,000	20,000
1							—
2							—
3							—
4							—
5							—

		% Salary Paid by Sources
	Job Title	% Salary paid by CRCCP	% Salary paid by CDC CCCP	% Salary paid by the state	% Salary paid by other source
ex 1	Project Manager	50%		50%
ex 2	Data Manager	100%
1
2
3
4
5

Instructions:

Please provide information on one row for each employee in your program. Under "FTE" provide the total proportion of time employed (includes all CRCCP activities). Report the number of hours worked per week and also the number of months based on all CRCCP program activities.

Under the salary columns, please indicate the base salary and fringe (again for CRCCP program activities). The total will be calculated automatically. Please report only the information for positions that were filled at some point during the fiscal year. Please use the comments box at the bottom of the screen to describe positions that were vacant during the fiscal year. Note that salaries and fringe benefits reported in this section should include all benefits received by staff in the calculations of total salaries. Use the comments box at the bottom of the screen to describe the method for including paid leave in the calculations. For a staff member whose salary has changed during the fiscal year, please report a prorated salary if possible. For example, if a staff member has an annual salary of $30,000 for the first four months of the fiscal year and an annual salary of $33,000 for the last eight month of the fiscal year, please prorate as follows:

Prorated annual salary = (4/12)($30,000) + (8/12)($33,000) = $32,000.00

If there are several salary changes for a given staff member within the fiscal year,
or it is otherwise difficult to calculate a prorated salary, please take a simple average.

Next, for each employee, please enter the % of salary paid by CRCCP funds and other funds. For example, 50% of a person’s salary could be paid by CRCCP and 50% could be paid by the state. Please make sure all percentages add to 100%.

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

5. PERSONNEL ACTIVITIES

Overview:

This worksheet collects information on the percentage of time spent on each specific CRCCP activity by each staff member (entered in section 4 as described above). Examples are provided below for Project Manager and Data Manager. Please note that a description of each activity is provided in Appendix A of this guide.

View of Screen 5:

		(e.g.) Project Manager	(e.g.) Data Manager
Program Management		50%
Screening Promotion Activities
– Client reminders
– Small media
– Provider assessment and feedback
– Provider reminders
– Reduction in structural barriers
– Patient navigation and support
– Reduction in out-of-pocket costs
– Enrolling in insurance programs
– Other screening promotion activities
Screening Provision Activities
– Establishing provider contracts and billing systems
– Providing screening and diagnostic services
– Ensuring appropriate treatment for complications and cancers
Quality Assurance and Professional Development
Partnership Development and Maintenance		50%
Clinical and Cost Data Collection and Tracking			85%
Program Monitoring and Evaluation			15%
Other Activities
		100%	100%

Instructions:

Please provide information in one column for each employee in your program. The title of each staff member will be automatically copied from the "personnel expenditure" section. For each staff member, please fill the cells with the percent of total time spent on each activity (include only activities specific to CRCCP). The percent time spent on all activities per person should equal 100%. For example, a program director may only spend 10% of his/her time on CRCCP activities and 90% of his/her time on other programs. If his/her 10% time dedicated to the program is spent half on Program Management and half on Partnership Development, then each of those categories would be recorded as 50% for a total of 100%. Examples of specific tasks to be included under each activity category are provided in Appendix A.

6. CONSULTANT/CONTRACT EXPENDITURE

Overview:

This worksheet collects information on costs related to consultants. A consultant is defined as an individual with whom you have a formal relationship to perform CRCCP related activities. For example, this could be a media specialist who designs a brochure for outreach activities or an endoscopist who performs colonoscopies. Contract, for the purposes of this data collection effort, is defined as a formal relationship with any organization or business (for example, a community based organization or company that prints the materials for outreach activities). The terms consultants and contracts are often used interchangeably, therefore we request that you only provide the information on a consultant or contract once, either in worksheet 6 (consultants) or worksheet 8 (contracts).

View of Screen 6:

	Job Title	Annual Payment	Activity 1	% Time Activity 1	Activity 2	% Time Activity 2	Activity 3	% Time Activity 2	Total Percent Time
ex 1	Public Relations	$30,000	Small media	100%					100
1
2

Instructions:

We are requesting information on consultant title, payment, and proportion of time spent on CRCCP activities. Please complete one line in the worksheet for each consultant.

Step 1: “Job Title”: From the drop down box, please select a title for the consultant. Please use the rows highlighted in purple to enter additional titles than those provided in the drop down boxes.

Step 2: “Annual Payment”: Enter the total amount of payments made to consultants during the project year. For example, if you have a contract with a public relations firm for $30,000 for the entire year, please indicate only the amount that was received by the consultant for the requested period. The “Total cost of consultants” will be calculated for you at the bottom of this column.

Step 3: “CRCCP Activity 1”, “CRCCP Activity 2”, and “CRCCP Activity 3”: From the drop down boxes in these three columns, select up to three main activities performed for the CRCCP by the consultant. If an individual performs less than three activities, please leave unneeded columns blank.

S

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

tep 4: “% Time CRCCP Activity 1”, “% Time CRCCP Activity 2”, and “% Time CRCCP Activity 3”: Enter the percent of time spent on each activity in the respective columns. The percentage allocated to all activities should total 100%.

7. SCREENING COSTS

7A. Screening and Diagnosis Costs

This worksheet collects data for the various screening and follow-up tests provided. All awardees are requested to report costs associated with pre-screening exams, bowel preparation, screening tests and diagnostic follow-up tests -- by type of screening test. The types of screening tests are in the column headings and include: FOBT, FIT, Sigmoidoscopy, Colonoscopy, DCBE, CT colonography, Other (specify). Only provide screening and diagnosis costs for the program year (for procedures that occurred during the annual reporting period). Costs for surveillance procedures (i.e. colonoscopies performed on individuals who have been diagnosed with a polyp or cancer) should be reported separately from the costs of screening/diagnostic tests.

View of Screen 7A:

Cost of Screening and Diagnostic Testing
	$ Amount
	FOBT	FIT	Sigmoidoscopy	Colonoscopy	DCBE	CT Colonography	Other: Specify
Pre-screening exams
Electrocardiogram (EKG)
Blood work
Office visit fee
Other
Bowel preparation
Screening tests
Take-home fecal occult blood test (FOBT)
Take-home fecal immunochemical test (FIT)
Sigmoidoscopy
Colonoscopy
Double-contrast barium enema (DCBE)
CT colonography (Virtual colonoscopy)
Anesthesia fee
Facility fees
Other
Diagnostic follow-up tests
Bowel preparation
Colonoscopy
Double-contrast barium enema (DCBE)
Pathology fees
Anesthesia fee
Facility fees
Other
Total cost of screening and follow-up
Cost of Surveillance Colonoscopy

Instructions:

Please enter the following information by screening test [FOBT, FIT, sigmoidoscopy, colonoscopy, DCBE, CT colonography, other (specify)]. Please report all costs associated with a selected test in a single column. For example, if the program provided 100 colonoscopies, then the screening costs and all pre- and post-screening exams/tests will be reported in the colonoscopy column for all 100 tests. The totals at the bottom of each column will indicate the total cost of providing all exams and tests for individuals screened using the selected screening test (FOBT, colonoscopy etc.).

“Pre-Screening Exams”: Enter the dollar amounts for the cost of all pre-screening exams including EKG and laboratory tests that were performed. If there are tests other than the ones specified, please select the “other” category and specify the test in the column cell indicated with “specify here”. Please add more rows if you have more tests.

Bowel Preparation and Anesthesia: Enter the dollar amount for the cost of all bowel preparations.

“Screening Tests”: Enter the dollar amounts for the cost of all tests that were performed. If there are tests other than the ones specified, please select the “other” category and specify the test in the column cell indicated with “specify here”. Please add more rows if you have more tests. Also indicate anesthesia and facility fees incurred during screening.

“Diagnostic Follow-Up Tests”: Enter the dollar amounts for the costs of all follow-up tests that were performed. If you would like to enter a test that is not included, please choose the “other” category and specify the test in the column cell indicated with “specify here”. Please add more rows if you have more tests. Also indicate any pathology, anesthesia and facility fees that were incurred.

The total costs by screening/diagnostic tests are automatically calculated in the yellow cell.

Please enter the cost incurred for surveillance in the category “Surveillance Colonoscopy”: Indicate the cost of all surveillance colonoscopies, i.e. colonoscopy on a person who has a prior history of adenoma(s) or colorectal cancer. The individual may have been screened either through the CRCCP or outside of the program.

7B. Screening and Diagnosis In-Kind Costs

Please follow the directions in 7A to complete this table. However, only include the costs of those services that were provided as in-kind contributions during the program year/reporting period. For example, cost of donated FOBT kits.

7C. Number of People Screened and Number of People Enrolled in Insurance Programs

This worksheet collects data on the number of people screened through various methods as well as the number of people enrolled in insurance programs due to CRCCP activities.

Note: Information on the number of individuals screened and those receiving surveillance is not required for programs that only provide these services using CRCCP funds. We can obtain the details required from the CCDE data. Programs that use other funds for these services should provide the total numbers for their program (CRCCP and other funding sources).

View of Screen 7C:

Number of People Screened and Number of People Enrolled in Insurance Programs

	FOBT	FIT	Sigmoidoscopy	Colonoscopy	DCBE	CT Colonography	Other: Specify	Total
Total number of individuals screened								0
Total number of screening tests performed								0
Total number of follow-up colonoscopies								0
Total number of adenomatous polyps/lesions detected								0
Total number of cancers detected								0
Total	0	0	0	0	0	0		0
Total Number of Individuals Undergoing Surveillance
Total Number of Individuals Enrolled in Insurance Programs

Instructions:

Please provide all the information requested in this section based on the number of procedures that were provided during the program year.

“Total Number of Individuals Screened:” Please provide the number of people screened for the current program year by the type of screen. For example, if the program provided 100 FOBTs and 50 colonoscopies, place “100” in the FOBT column and “50” in the colonoscopy column. The total number of individuals screened is automatically calculated.

“Total Number of Screening Tests Performed.” Please provide the number of screening tests performed for the current program year. Include repeat or follow-up screenings if they occurred within the same program year. For example, if a person had an FOBT and a follow-up FOBT within the same program year, count as 2 FOBTs.

“Total number of follow-up colonoscopies.” Please provide the number of follow-up colonoscopies performed for the current program year in the cell intersecting the column labeled “Colonoscopy” and the row labeled “Total number of follow-up colonoscopies.”

“Total number of adenomatous polyps/lesions detected.” Please provide the total number of adenomatous polyps/lesions detected for the current program year by the type of screen.

“Total number of cancers detected.” Please provide the total number of cancers detected for the current program year by the type of screen used to detect the cancer.

“Total Number of Individuals Undergoing Surveillance:” Please provide the number of individuals that were provided surveillance colonoscopy.

“Total Number of Individuals Enrolled in Insurance Programs:” Please provide the number of people that have been enrolled in any insurance program due to screening provision activities or screening promotion activities.

8. CONTRACTS, TRAVEL, MATERIALS OR SERVICES PURCHASED

Overview:

This worksheet collects expenditures on contracts, travel, materials, and services. Contracts with providers and other organizations for non clinical (screening and diagnostic testing) activities such as screening promotion activities should be reported in this section. This section also collects information on the method used to calculate the cost and the funding source. Please only report cost for the current program year.

View of Screen 8:

	Type of Service Purchased	CRCCP Activity	Amount ($)	Cost Calculation	Funding Source
ex 1	Sub-award to local health department	Client reminders	$10,000	Actual	Other
ex 2	Travel for Reverse Site Visit	Program Management	$ 5,000	Actual	CRCCP
	Total cost of contracts, travel, materials and supplies		-

Instructions:

In this worksheet, please use one row to report each contract, travel, material or service purchased. You can report travel grouped into relevant activities (i.e. report all travel related to one type of CRCCP activity in a single row).

Step 1: “Type of Service Purchased”—Indicate the type of cost incurred. Please refer to examples provided above (View Screen 7).

Step 2: “CRCCP Activity”—From the drop down box in this column, please select an activity for which the cost was incurred. If it is for the program in general and cannot be assigned to a category, please enter ‘n/a’ (not applicable).

Step 3: “Amount”—Enter the amount of expense incurred only for the current program year.

Step 3: “Cost Calculation”—Please select whether the amount was based on “actual” cost or an “estimate” from the drop down list provided.

Step 4: “Funding Source”—From the drop down box in this column, please select the funding source (“CRCCP”, “state” and “other”).

Check Post 5: Please indicate any donated or in-kind non-labor contributions in the “In-Kind” worksheet (Worksheet 3).

9. ADMINISTRATIVE COSTS

Overview:

This section collects information on administrative cost allocation methodology, the types of costs included in the administrative or overhead cost categories, and amount of such costs.

View of Screen 9A (Allocation methodology):

9A. Allocation Methodology		Y/N		$ Amount
Proportion of direct cost				0
Please indicate percent of direct cost used			%
Lump-sum payment				0
Other: specify _______________________				0

View of Screen 9B (Administrative, indirect or overhead costs):

9B. Types of costs included in the administrative or overhead costs reported above:	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 9A, provide the allocation methodology/methodologies used for administrative costs. Indicate whether administrative costs are a proportion of direct costs. If yes, provide the percent or dollar amount. If no, indicate the lump-sum amount or other methodology and amount.

Under 9B, provide details on the total lump sum payment made and whether costs associated with rent, repairs/maintenance, network connection/maintenance, phone service, and shared office equipment, are included in the lump sum administrative cost. If these are paid for as specific line item charges in addition to the administrative costs, please provide the dollar amounts.

10. SUMMARY DATA SHEET

Please review the summary information to ensure that the difference reported between total expenditure and total cost allocated to activities is zero. If the difference is not zero, please review the data entries and correct any errors.

11. CONFIRMATION OF COST DATA

Please verify that all relevant fields have been completed on all 11 CAT screens and that you have reviewed the summary data sheet. The data will be submitted when you click the “Confirm Cost Data Complete” button.

Thank you for completing this questionnaire.

APPENDIX A: DESCRIPTION OF PROGRAM ACTIVITIES

Program Activity	Description
1. Program Management	Establish specific, measurable and realistic objectives; Recruit, hire, and train staff; Develop a fiscal system; Develop administrative-related policies and procedures; Manage programmatic/administrative/reporting issues; travel for program meetings; Integrate program management functions with existing CRC screening programs and/or other cancer screening or chronic disease programs;
2. Screening Promotion Activities
2a) Client Reminders	Reminders include letters, postcards, or phone calls to alert clients that it is time for their cancer screening
2b) Small Media	Small media include videos and printed materials such as letters, brochures, and newsletters. These materials can be used to inform and motivate people to be screened for cancer. They can provide information tailored to specific individuals or targeted to general audiences.
2c) Provider Assessment and Feedback	These interventions assess how often providers offer or deliver screening services to clients (assessment) and then give providers information about their performance (feedback). The feedback may describe the performance of an individual provider or of a group of providers (e.g., mean performance for a practice). The performance may be compared with a goal or standard.
2d) Provider Reminders	Reminders inform health care providers it is time for a client’s cancer screening test (called a “reminder”) or that the client is overdue for screening (called a “recall”). The reminders can be provided in different ways, such as in client charts or by e-mail.
2e) Reduce Structural barriers	Many barriers can make it difficult for people to seek screening for cancer. They include distance from screening location, limited hours of operation, lack of daycare for children, and language and cultural factors. These types of interventions seek to increase screening by removing structural barriers. (please report navigation in the section below)
2f) Patient Navigation and Support	Establish a patient support system and/or use patient navigators to ensure appropriate screening, diagnostic, and treatment services are received in a timely manner.
2g) Reduce Out of Pocket Costs	Interventions could include reducing the costs of the screening tests, providing vouchers, reimbursing clients or clinics, and/or reducing health insurance costs.
2h) Enroll in Insurance Programs	Assist individuals eligible for Medicaid or other insurance programs to enroll
2i) Other Screening Promotion Activities (please specify)	Report any additional screening promotion activity that is not reportable under the above options

Program Activity	Description
3. Screening Provision Activities
3a) Establish provider contracts, billing systems and other procedures	Identify and contract with local physicians and clinics to deliver screening services; Establish the necessary administrative billing and reimbursement system; Convene MAB and develop necessary screening protocols
3b) Provide screening and diagnostic services	Provide CRC pre-screening, screening, diagnostic follow-up, and surveillance colonoscopy services.
3c) Ensure appropriate treatment for complications and cancers	Develop a plan, including identifying funding sources, for assuring treatment services for people diagnosed with cancer or experiencing medical complications
4. Quality Assurance and Professional Development	Develop quality control standards and mechanisms; Develop clinical policies and procedures; Develop or enhance training to educate/train health care professionals
5. Partnership Development and Maintenance	Maintain a relationship with the CDC-funded comprehensive cancer control (CCC) implementation program Develop and maintain partnerships with diverse group of entities
6. Clinical and Cost Data Collection and Tracking	Establish a patient data tracking system; Develop/adapt data collection for reporting person level clinical data; Collect and report cost data
7. Program Monitoring and Evaluation	Collaborate with CDC in the monitoring and evaluation of the program Plan and implement program-specific monitoring and evaluation efforts

APPENDIX B: DROP DOWN BOX CATEGORIES

Program activities

Program Management

Screening Promotion Activities

– client reminders

– small media

– provider assessment and feedback

– provider reminders

– reduction in structural barriers

– patient navigation and support

– reduction in out-of-pocket costs

– enrolling in insurance programs

Screening Provision Activities

– establishing provider contracts and billing systems

– providing screening and diagnostic services

– ensuring appropriate treatment for complications and cancers

Quality Assurance and Professional Development

Partnership Development and Maintenance

Clinical and Cost Data Collection and Tracking

Program Monitoring and Evaluation

Other Activities

Source of Non-Federal Funds

American Cancer Society (ACS)

State funds

In-Kind--Labor

IT Support

MAB

Provider Services

In-Kind-- Non Labor

Computer and Other Electronics

Furniture

Office Supplies

Value Estimation Method for In-Kind Contribution

Market Price

Percentage of Staff Salary

Other

Job Titles

Senior Manager

Executive Director

Project Director

Chief Medical Officer

Epidemiologist

Data Manager

Health Educator

Patient Navigator

Project Nurse

Sr. Administrative Assistant

Administrative Assistant

Project Coordinator

IT Specialist

Fiscal Assistant

Accountant

Health Surveillance Specialist

Practice Manager

Case Manager

Clinic Manager

Social Worker

Graduate Intern

Family and General Practitioner

Internist (Gastroenterologist)

Surgeon

Nurse

Consultants

Outreach Specialist

Public Health Nurse

Social Worker

Co-coordinator

Media/marketing Specialist

Info Tech Specialist

Local Colorectal Cancer Control Programs

Alabama

Alaska Native Tribal Health Consortium (Tribal Organization in Alaska)

Arizona

Arctic Slope Native Association (Tribal Organization in Alaska)

California

Colorado

Connecticut

Delaware

Florida

Iowa

Maine

Maryland

Massachusetts

Minnesota

Montana

Nebraska

New Hampshire

New Mexico

New York

Oregon

Pennsylvania

South Dakota

South Puget Intertribal Planning Agency (Tribal Organization in Washington)

Southcentral Foundation (Tribal Organization in Alaska)

Utah

Washington

Funding Source

CRCCP

State

Other

Type of Staff or Volunteer

CRCCP Funded

Provider

MAB

Other

Cost Calculation

Actual

Estimate