GenIC XDRCI-COST

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Overview

Prep & Initial assessments
Follow-up to this point

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Sheet 1: Prep & Initial assessments

			Attachment Cb. State and County Representative Data Collection Instrument
			XDR TB Contact Investigation: A Cost Assessment		Form Approved
			Costs to state health departments		OMB No. 0920-0879
					Expiration Date 03/31/2018
			Preparation for the contact investigation and initial assessments of each contact
			Today's date	1/26/2021
			Date that data provided to the CDC represents as endpoint of data collection
		1	Location and collaborator information	Name	Job title
0	1		State
0	2		Who reported the data collected in this sheet?
		2	Contact investigation outcomes	Number	Notes
2	3		Total number of hours identifying contacts in your state
2	4		Total number of contacts identified in your state
2	5		Number of high priority contacts or 'close contacts'
2	6		Number of medium priority contacts
2	7		Number of low priority contacts or 'casual contacts'
2	8		Total number of contacts evaluated for TB in your state
1	9		How confident are you that this represents the total number of actual contacts?
		3	Tests and results for TB infection and disease	Administered	# positive	# negative	# indeterminate	Notes
			Tuberculin skin testing
2	10		Number of tuberculin skin test (TST) placements with TB education
5	11		Number of TST test readings
			IGRA testing
5	12		Number of QuantiFERON Gold In-tube (QFT-GIT) IGRA tests
5	13		Number of T-spot IGRA tests
			Testing for TB disease
5	14		Number of physical examinations
5	15		Number of chest x-rays (CXR)
2	16		Number of sputum inductions
5	17		Number of smear microscopy and culture tests
5	18		Number of nucleic acid amplification (NAA) tests
		4	Risk factors for developing TB disease after infection	Number	Notes
			Number of contacts who were born in any of the following regions
2	19		Africa
2	20		Asia
2	21		Pacific Islands
2	22		Central America
2	23		South America
2	24		Mexico
2	25		Eastern Europe
2	26		Caribbean
2	27		Middle East
2	28		Other
			Number of contacts who have lived or travelled in any of the following regions for more than one month
2	29		Africa
2	30		Asia
2	31		Pacific Islands
2	32		Central America
2	33		South America
2	34		Mexico
2	35		Eastern Europe
2	36		Caribbean
2	37		Middle East
2	38		Other
			Medical risk factors
2	39		Number of contacts with a history of LTBI
2	40		Number of contacts with a history of TB disease
2	41		Number of contacts that had received the BCG vaccine
2	42		Number of contacts with diabetes
2	43		Number of contacts with HIV/AIDS
2	44		Number of contacts with autoimmune disease or other immunosuppressive condition
2	45		Other
			Non medical risk factors
2	46		Number of contacts that were close contacts of someone with TB disease other than the index case
2	47		Number of contacts under 5 years old
2	48		Number of contacts that have been a resident of a correctional facility in the past year
2	49		Number of contacts that have ever used injection drugs
2	50		Number of contacts that were homeless in the past year
2	51		Other
		5	Cost of testing for TB infection and disease	Cost per service	Who paid for it	Notes	For checking
3	52		Tuberculin Skin Tests (TST)
3	53		Quantiferon Gold In Tube (QFT-GIT) IGRAs				no
3	54		T-spot IGRAs				no
3	55		Physical examinations				no
3	56		Chest X-rays (CXR)				no
3	57		Sputum inductions				no
3	58		Sputum smear and cultures				no
3	59		Nucleic acid amplification (NAA) tests				no
		6	Cost of testing for other illnesses that are risk factors for TB disease	Number of services provided	Cost per service	Who paid for it	Notes
			HIV testing
4	60		ELISA
4	61		Western blot
4	62		Rapid diagnostic test
			Diabetes testing
4	63		Hemoglobin A1C test
4	64		Blood glucose test
			Kidney disease testing
4	65		Urinalysis
4	66		Ultrasound
4	67		Computerized tomography
4	68		Biopsy
			Any other test
4	69		please indicate
			etc
		7	Cost of LTBI treatment	Number of regimens initiated	Cost per dose	Doses taken	Who paid for it	Notes
5	70		6H Isoniazid (INH)
5	71		9H Isoniazid (INH)
5	72		4R Rifampin (RIF)
5	73		3HT Isoniazid (INH) Rifapentine (RPT)
5	74		Cycloserine (CYC)
		8	Personnel costs	Number of personnel	Total hours spent on XDR contact investigation	Gross Annual Salary without benefits	Percent fringe benefit	Who paid for it	Notes
			Investigative personnel
7	75		Outreach workers
7	76		Nurse consultants
7	77		Statisticians
7	78		Epidemiologists
7	79		Translators
			Health care providers
7	80		Nursing supervisors
7	81		Nurses
7	82		Physicians
7	83		Counsellors
7	84		Social workers
7	85		Volunteers
			Administrative personnel
7	86		Program managers
7	87		Administative clerks
7	88		Health information technicians
7	89		Receptionists
7	90		File clerks
			Laboratory personnel
7	91		Lab technicians
7	92		Radiology technicians
			State Department of Health and TB Controllers Office
7	93		Director
7	94		Assistant director
7	95		Chief of staff
7	96		Infectious diseases chief
7	97		Infectious diseases deputy
7	97		TB controller
7	98		Chief nurse consultant
7	99		Communications officers
7	100		Other
			Other personnel
7	101		Please indicate
			etc
			Check	0
		9	Travel costs	Total units used or consumed	Total amount spent	Who paid for it	Notes
			Vehicle Use (miles)
4	102		Vehicle 1
4	103		Vehicle 2
			etc
4	104		Per diem
4	105		Other
			etc
		10	Training costs	Total number of each personnel category receiving training	Number of personnel receiving training who were involved in the contact investigation or support	Cost per training course	Duration of the training validity	Proportion dedicated to the XDR contact investigation	Who provided the training? (external, or in-house)	Who paid for it	Notes
			Training 1
8	106		Participant personnel category 1
8	107		Participant personnel category 2
			etc
			Training 2
8	108		Participant personnel category 1
8	109		Participant personnel category 2
			etc
		11	Costs of incentives and enablers	Units consumed	Cost per item	Who paid for it	Notes
			Incentives to come to health center
4	110		Please list
			etc
			Enablers to come to health center
4	111		Please list
			etc
		12	Any other miscellaneous costs	Units consumed	Cost per unit	Percent dedicated to XDR contact investigation	Who paid for it	Notes
5	112		Please indicate
464	Total blanks on this page		CDC estimates the average public reporting burden for this collection of information as 2 hours (1.5 hours for the program manager, and 30 minutes for the accountant
			including the time for reviewing instructions, searching existing data/information sources,
807	Total blanks on spreadsheet		gathering and maintaining the data/information 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 burden to CDC/ATSDR
			Information Collection Review Office,
			1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).

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Sheet 2: Follow-up to this point

			Costs to state health departments
			Estimated cost of investigating and following contacts of an extensively drug resistant patient in the United States
			Follow-up period to this point
		13	Tests and results for TB infection and disease	Administered	# positive	# negative	# indeterminate	Notes
			Tuberculin skin testing
2	113		Number of tuberculin skin test (TST) placements with TB education
5	114		Number of TST test readings
			IGRA testing
5	115		Number of QuantiFERON Gold In-tube (QFT-GIT) IGRA tests
5	116		Number of T-spot IGRA tests
			Testing for TB disease
5	117		Number of physical examinations
5	118		Number of chest x-rays (CXR)
2	119		Number of sputum inductions
5	120		Number of smear microscopy and culture tests
5	121		Number of nucleic acid amplification (NAA) tests
		14	Cost of testing for TB infection and disease	Cost per service	Who paid for it	Notes
			Tuberculin skin testing
3	122		Number of tuberculin skin test (TST) placements with TB education
3	123		Number of TST test readings
			IGRA testing
3	124		Number of QuantiFERON Gold In-tube (QFT-GIT) IGRA tests
3	125		Number of T-spot IGRA tests
			Testing for TB disease
3	126		Physical examinations
3	127		Chest X-rays (CXR)
3	128		Sputum inductions
3	129		Sputum smear and culture tests
3	130		Nucleic acid amplification (NAA) tests
		15	Cost of LTBI treatment	Cost per dose	Doses taken	Who paid for it	Notes
4	131		6H Isoniazid (INH)
4	132		9H Isoniazid (INH)
4	133		4R Rifampin (RIF)
4	134		3HT Isoniazid (INH) Rifapentine (RPT)
4	135		Cycloserine (CYC)
		16	Personnel costs	Number of personnel	Total hours spent on XDR contact investigation	Gross Annual Salary without benefits	Percent fringe benefit	Who paid for it	Notes
			Investigative personnel
7	136		Outreach workers
7	137		Nurse consultants
7	138		Statistician
7	139		Epidemiologist
7	140		Translators
			Health care providers
7	141		Nursing supervisors
7	142		Nurses
7	143		Physicians
7	144		Counsellors
7	145		Social workers
7	146		Volunteers
			Administrative personnel
7	147		Program managers
7	148		Administative clerk
7	149		Health information technicians
7	150		Receptionists
7	151		File clerks
			Laboratory personnel
7	152		Lab technicians
7	153		Radiology technicians
			State Department of Health and TB Controllers Office
7	154		Director
7	155		Assistant director
7	156		Chief of staff
7	157		Infectious diseases chief
7	158		Infectious diseases deputy
7	159		TB controller
7	160		Chief nurse consultant
7	161		Communications officers
7	162		Other
			Other personnel
7	163		Please indicate
			Check	0
		17	Travel costs	Total units used or consumed	Total amount spent	Who paid for it	Notes
			Vehicle Use (miles)
4	164		Vehicle 1
4	165		Vehicle 2
			etc
4	166		Per diem
4	167		Other
			etc
		18	Training costs	Total number of each personnel category receiving training	Number of personnel receiving training who were involved in the contact investigation or support	Cost per training	Duration of the training validity	Proportion dedicated to the XDR contact investigation	Who provided the training	Who paid for it	Notes
			Training 1
8	168		Participant personnel category 1
8	169		Participant personnel category 2
			etc
			Training 2
8	170		Participant personnel category 1
8	171		Participant personnel category 2
			etc
		19	Costs of incentives and enablers	Units consumed	Cost per item	Who paid for it	Notes
			Incentives to come to health center
4	172		Please list
			Enablers to come to health center
4	173		Please list
		20	Any other miscellaneous costs	Units consumed	Cost per unit	Percent dedicated to XDR contact investigation	Who paid for it	Notes
5	174		Please indicate
343	Total blanks on this page