Form 1 Teaching Health Center Costing Instrument

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]

THCGME Residency Costing Instrument
Please Enter:
Name of Residency Program you are providing information on in this workbook:
THC Program Specialty:
Residency Accreditation:
Please indicate the type of Sponsoring Institution for the Residency Program:
How many residency continuity clinic sites do you have?
Please indicate the name(s) of the continuity clinic that you are providing financial information on in
this workbook.
Please indicate the licensure(s) for the residency continuity clinic that you are providing financial
information on in this workbook (please specify if other or list multiple):
Time Period (Day/Month/Year - Day/Month/Year):
New or Expansion Program Under THC Grant:
Accredited Class Size per Year (if expansion, put THC and non-THC residents)
Contact Person:
Contact Person's E-mail:
Contact Person's Telephone:
Reviewer(s)/Contributor(s)
Signatories
Thank you for your assistance in completing this residency program costing instrument. The information gathered here will be important to inform your THCGME program officers better understand the costs of residency training
programs and natural variations that occur between THC programs.
This costing instrument does request detailed information about your residency program. Your faculty scheduling staff and your health center and residency program accounting staff may be best equipped to fill in the needed
information.

General Instructions (Detailed Instructions on Each Page):
Enter data into clear cells, and add any additional explanations into orange cells. Gray cells include formulas, and have been locked to prevent accidental changes.
Please enter data for your most recent completed full academic or fiscal year (fill in above), based on your organization's accounting practices.
Please fill out the following worksheets: Visits, Revenue, Fac Salaries Benefits, Precepting Contracts, Residents Salaries Benefits, ResidencyAdmin, ClinicOperations, ClinicAdmin, Staffing, and StartUp. There are no cells to fill in on
the Summary worksheet. It will auto-populate based on the other worksheets. However, we recommend you review the Summary worksheet prior to submitting the instrument.
Please be consistent in the sites, departments, and clinical service lines you report on, according to the following guidelines:
a. For patient visits, revenue, faculty and provider FTE, clinic operations and administration, please match your reports across these areas. For example, report patient revenues and clinic operations/administration
expenses for the total visits reported in the Visits worksheet.
b. Please report for the resident continuity clinic and inpatient service lines to the smallest units possible given your organization's accounting practices. For example, if it is possible to report clinic
operations/administration expenses, visits, and patient revenue for the residency specialty clinic service in the resident continuity clinic site only, excluding other service lines (such as other specialties, pharmacy, lab, xray, etc.), then please report to this level of detail.
c. If certain expenses are shared across more than one residency program, please report on only the proportion of the cost/revenue that can be estimated to be attributable to the residency program that you cite above.
Please also only restrict your revenues to the proportion that are attributable to the site for which you are reporting.
We understand accounting lines may differ between THC programs. Please use your best judgement on where to enter expenses. Do not enter an expense more than once. For example, if you report an expense in the residency
administration worksheet (such as malpractice insurance), do not include that expense when reporting similar expenses in other worksheets.
Public Burden Statement: 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. The OMB control number for this project is 0906‐XXXX. Public reporting burden for this collection of information is estimated to average XX hours per response, including the time for
reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10C‐03I, Rockville, Maryland, 20857.

OMB Number 0906-XXXX and Expiration date XX/XX/201X

Basic Info

Page 1

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]
Name of Program:
THC Program Specialty:
Time Period:

0

Summary Page - This page will be autopopulated by your answers in the following worksheets.

Total
Resident and Faculty FTE's:
Resident FTE
Faculty FTE

Program Expenses:
Personnel Expenses:
Faculty Salaries/Benefits
Precepting Contracts
Resident Salaries/Benefits
Sub-Total
Residency Program Administration:
Residency Administrative Personnel
Education Costs
Resident Education Stipends
Resident Required Training
Simulation Center Costs
Education Supplies
Medical/Dental School or OPTI fees
Inpatient Service Costs
Licensing and Certification Fees
Licensing Examination Fees
In-Service Examination Fees
Board Certification Fees
Licensing Fees
Program Fees and Costs
Accreditation Fees
NRMP/Match Participation Fees
Recruitment Costs
Graduation Costs
Faculty/Staff Development
Travel
General Liability Insurance
Malpractice Insurance
Legal and Accounting
Consortium Expenses (if applicable)
Rent/Occupancy
Supplies
Mobile Communications Devices
IT Costs
White Coats/Uniforms
Office Supplies
Other
Sub-Total

Resident Clinic
(Precepted
Ambulatory
Visits)

Resident
Inpatient
Service

N/A

N/A

N/A

0.00
0.00

Visits:
Clinic Visits
Inpatient Visits
Clinic Sessions
Revenue:
Net Clinic Pt Revenue
Net Inpatient Pt Revenue
FQHC Grant
Other Patient Service Grants
Hospital Residency Funding
THC Grant
Medicaid GME
Other Residency Support
Total Revenue

Faculty Practice
(ambulatory,
not precepted)

0.00

0
0
0

$
$
$

-

$
$
$
$
$

-

$

0

#REF!

$

0.00

#REF!

Residency
0.00
0.00

0.00

0

N/A

N/A
0

N/A
0

N/A

#DIV/0!
N/A
#DIV/0!
#DIV/0!
N/A
N/A
N/A
N/A
#DIV/0!

#DIV/0!
N/A
#DIV/0!
#DIV/0!
N/A
N/A
N/A
N/A
#DIV/0!

N/A
#VALUE!
N/A
#VALUE!
N/A
N/A
N/A
N/A
#VALUE!

#DIV/0!
N/A
N/A
#DIV/0!

#DIV/0!
N/A
N/A
#DIV/0!

$

N/A
N/A
N/A

N/A
N/A
N/A
N/A
$
$
$
$
$

N/A
N/A

$

-

$

#REF!

$
-

#REF!

$

-

N/A

N/A

N/A

$
$
$
$
$
$

-

N/A
N/A
N/A
N/A
N/A
N/A

N/A
N/A
N/A
N/A
N/A
N/A

N/A
N/A
N/A
N/A
N/A
N/A

$
$
$
$
$
$

-

$
$
$
$

-

N/A
N/A
N/A
N/A

N/A
N/A
N/A
N/A

N/A
N/A
N/A
N/A

$
$
$
$

-

$
$
$
$
$
$
$
$
$
$
$

-

N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A

N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A

N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A

$
$
$
$
$
$
$
$
$
$
$

-

$
$
$
$
$
$

-

N/A
N/A
N/A
N/A
N/A

N/A
N/A
N/A
N/A
N/A

N/A
N/A
N/A
N/A
N/A

$
$
$
$
$
$

-

Clinic Operations Expenses:
Clinical Support Personnel Salaries/Benefits
Purchased Medical Services
Medical Supplies
Medical Equipment
Licensing Fees
Malpractice Insurance
EHR licenses/maintenance
Uniforms
Occupancy
Depreciation
Other
Sub-Total

$
$
$
$
$
$
$
$
$
$
$
$

-

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

$

-

Clinic Administration Expenses:
Administrative Personnel Salaries/Benefits
Purchased Admin Services
Office Supplies
Recruitment
Staff Development
Travel
IT Infrastructure
Other
Sub-Total

$
$
$
$
$
$
$
$
$

-

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

$
$
$
$
$
$
$
$
$

-

#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!

$

N/A
#DIV/0!
#DIV/0!

N/A
#DIV/0!
#DIV/0!

Total Program Expense
Overall Profit/Loss
Residency Overhead
Clinical Overhead
Total Overhead

#REF!
#REF!
$
$
$

-

$

-

$

-

$

-

N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A

N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
#DIV/0!
N/A
N/A
$

$

-

N/A
N/A
N/A

-

N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
#REF!
#REF!

#VALUE!

Excluding Overhead:
Residency Program Cost * **
Cost per Resident
Including Overhead:
Residency Program Cost * **
Cost per Resident
*Residency program cost and cost per resident exclude explicit residency program funding
** Faculty Practice revenue and expense, non precepted, is not included in the Cost per Resident calculations

OMB Number 0906-XXXX and Expiration date XX/XX/201X

-

$

N/A

$

-

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

Summary

Page 2

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]

Name of Program:
THC Program Specialty:
Time Period:

0

Patient Visits
Instructions:
Report for the resident continuity clinic and inpatient service lines to the smallest units possible given your organization's accounting practices.
* For example, if it is possible to report clinic operations/administration expenses, visits, and patient revenue for the residency specialty clinic service in the resident continuity clinic site only,
excluding other service lines (such as other specialties, pharmacy, lab, x-ray, etc.), then please report to this level of detail.
Enter the total number of clinical sessions matched to the reported visits. A session can be a morning, afternoon, or evening session. Sessions should be reported for all relevant providers.
* For example, if 4 providers are working during a morning session, the total sessions would equal 4.
For the Inpatient Service, enter the total patient visits for all revenue generating services where residents provide care on a continuous basis
Faculty Practice visits should include patient visits for faculty in the THC residency program specialty in the residency continuity clinic sites.
* For example, if your THC program is a family medicine program, only enter patient visits for family medicine faculty when they are not precepting.
Numbers of Patient Visits/Sessions in the Reporting Year
Ambulatory Visits in the Resident Continuity Clinic
Non-Precepted

Visits
Clinic
Inpatient
Clinic Sessions

Total Medical or Dental

Residency Faculty
Practice

Non-Faculty
Providers

Residency Faculty Precepted
(Please enter the specialty of
non-faculty providers below)

PGY-1
Residents

PGY-2
Residents

PGY-3
Residents

PGY-4
Residents

N/A

N/A

N/A

N/A

Resident Total
(All PGYs +
Chiefs)
Chief Residents
0
N/A
N/A
0

Resident
Inpatient
Service (if
applicable)
N/A
N/A

Payer Mix:
Resident Site(s) Percent of Visits
Outpatient Service
Inpatient Service
Total Medicaid
Total Medicare
Dual Eligible (Medicaid &
Medicare)
Charity Care
Sliding Scale
Workman’s comp
Military Tri-Care
Number Written Off as Bad
Debt
Other Public
Total Private
Self-Pay
Total

OMB Number 0906-XXXX and Expiration date XX/XX/201X

-

Notes

-

Visits

Page 3

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]
Name of Program:
THC Program Specialty:
Time Period:

0

Patient Revenue
Outpatient Resident Clinic and Inpatient Revenue Instructions:
For Outpatient Revenue, enter the patient revenue generated in the residency continuity clinic site matched to the site listed in the first page, and used for the total
medical or dental visits and clinical operations and administration expenses reported.
* Full Charges should reflect the total full charges for services rendered to patients
* Amount Collected should reflect the gross receipts for the period on a cash basis, regardless of the period in which the paid for services were rendered
For the Inpatient Revenue, enter the total patient revenue matched to residency inpatient service visits reported
Outpatient Resident Clinic and Resident Inpatient Service
Outpatient Resident Clinic Revenue

Payer
Total Medicaid
Total Medicare
Dual Eligible (Medicaid & Medicare)
Charity Care
Sliding Scale
Workman’s comp
Military Tri-Care
Amount Written Off as Bad Debt
Other Public
Total Private
Self-Pay
Subtotals
Retroactive Settlements, Receipts, Paybacks:
Collections of Retroactive Payments
Penalty/Payback
Total Adjusted Revenue
FQHC Grant

Inpatient Resident Service Revenue

Full Charges This
Period

Amount Collected
This Period

Full Charges This
Period

Amount Collected
This Period

$

$

-

$

$

-

$

-

$

-

-

-

Space for THC to describe if
categories are combined, or
other explanations.

End Date of Grant/Renewable
or Non-renewable

Other Patient Service Grants:
Source
Source
Source
Source
Source
Total Patient Service Grants

$

-

$

.

-

Residency Program Funding
Instructions:
For Residency Program Funding, include only funding that explicitly supports resident training or other activities. For example, if your organization receives a "PCMH" grant
explicitly to support resident training in PCMH, include that grant here. If the PCMH grant supports clinical service in the site for which this workbook is covering, include the
grant in Other Patient Service Grants above.
Residency Program Funding
Hospital Residency Funding
THCGME Payment
Medicaid GME

Total Amount

End Date of Grant

Renewable or
Non-renewable

End Date of Grant

Renewable or
Non-renewable

Grants:
Source
Source
Source
Source
Source
Sub-Total Grants
Donations

Other:
Meaningful Use Incentives
Source
Source
Sub-Total Other
Total Grants & Other Residency Support

$

$
$

-

-

Medical Student Funding
Total Amount
Medical Student Funding

OMB Number 0906-XXXX and Expiration date XX/XX/201X

Revenue

Page 4

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]
Name of Program:
THC Program Specialty:
Time Period:

0

Faculty Salary and Benefits
Instructions:
To determine FTE allocation, please use actual data of time spent in the different areas from your most recently completed academic year
* In general, 1 session per week or 48 sessions per year is 0.1 FTE. Sessions can be a morning, afternoon or evening session, and are often approximately 4 hours.
For Total FTE, report the total time the individual works, matched to the Total Salary and Benefits reported.
* For example, if the individual works for the health center 0.5 FTE, enter 0.5 and the total salary and benefits correlated to that 0.5 FTE.
If there is insufficient space for core, part time, or other faculty, list additional faculty positions below. Totals will auto-populate the Additional Faculty line.
For Other Providers - Non-Teaching, report the total FTE for all non-teaching providers in the residency continuity clinic site related to the number of visits and revenue reported in the Visits and Revenue worksheets.
Include other specialty faculty in Residency Faculty FTE Allocations only if they have dedicated residency program time. Otherwise include in Other Providers - Non-Teaching if appropriate.
* For example, for a family medicine residency, include OB-Gyn, internal medicine, or pediatrics faculty only if they are covering resident inpatient services (including OB) or have dedicated residency teaching, curriculum, or administrative time
If benefit payments are reported separately from salary, report in the "Total Benefits" column. Otherwise include in the "Total Salary" column.

Residency Faculty FTE Allocations

Faculty Salaries and Benefits
Example - Core Faculty
Program Director
Associate Program Director
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Core Faculty
Part time faculty
Part time faculty
Part time faculty
Part time faculty
Behaviorist (if applicable)
Director of Research (if applicable)
Additional Faculty (See below)
Providers - Non-Teaching (e.g. MA, PA)
Total

Specialty
Internal Medicine

Additional Faculty Positions:

Total

OMB Number 0906-XXXX and Expiration date XX/XX/201X

Total FTE
1.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Total FTE
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Faculty
Practice
Resident Clinic
(Ambulatory,
(Precepted
Not
Ambulatory
Precepting)
Visits)
0.10
0.20

0.00

Resident
Inpatient
Service
0.10

Clinic Admin
0.10

0.00

0.00

0.00

0.00

0.00

0.00

N/A
0.00

0.00

0.00

$

-

$

-

0.00

0.00

$

-

$

-

-

Faculty
Resident Clinic
Practice
(Ambulatory,
(Precepted
Ambulatory
Not
Visits)
Precepting)
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
-

Residency
0.50

Residency
Other Grants
Description of
(NonActivities
Residency)
0.00

Total Salary
$
165,000

Total Benefits
$
39,600

N/A

Faculty
Resident Clinic
Practice
(Ambulatory,
(Precepted
Ambulatory
Not
Visits)
Precepting)

0.00

Cost
Faculty
Practice
Resident Clinic
(Ambulatory,
(Precepted
Not
Ambulatory
Precepting)
Visits)
$
20,460 $
40,920
$
- $
$
- $
$
- $
$
- $
$
#VALUE!
$
- $
$
- $
#VALUE!
#VALUE!
$
- $
$
- $
#VALUE!
#VALUE!
$
#VALUE!
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
#VALUE!
$
- $
-

0.00

Inpatient
Service

0.00

Clinic Admin

0.00

Residency

0.00

Residency
Notes

Other Grants
(NonResidency)

0.00

Total Salary

$

Total Benefits

-

Faculty Salaries

$

Resident
Inpatient
Service
$
20,460
$
$
$
$
$
$
$
#VALUE!
$
$
#VALUE!
#VALUE!
$
$
$
$
$
$
$
$
-

Inpatient
Service
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

Clinic Admin
$
20,460
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

Clinic Admin
$
-

$

-

Other Grants
Residency (Non-Residency)
$ 102,300 $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
#VALUE!
$
$
- $
$
- $
#VALUE!
$
#VALUE!
$
$
- $
$
- $
$
- $
$
- $
$
- $
$
- $
#VALUE!
$
$
- $
-

Residency
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
-

Other Grants
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

Page 5

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]
Name of Program:
THC Program Specialty:
Time Period:

0

Residency Program Precepting Contracts
Instructions:
Report the amount paid by the residency under "Total Amount for Contracts Paid by the Residency", and the amounts paid by the hospital under "Total Amount for Contracts Paid by the Hospital".
Enter the amount of any contracts with hospital or community preceptors to provide training experiences for your residents that are paid for by the residency.
In some situations, these fees are paid by the hospital rather than the residency program.
If this is the case for your program, please include the hospital payments under the "Total Amount for Contracts Paide by the Hospital" for contracts where the hospital makes the payments.

Preceptorships
Assistant Program Director
Medical Student Clerkship Director
Simulation Lead
Clinic Director

Total Amount for
Contracts Paid by the

Total Amount for
Contracts Paid by the

Behavioral Health
Community Preceptors
Critical Care
Emergency Medicine
Family Medicine
General Adult Medicine/Internal Medicine
General Pediatrics
General Surgery
Geriatrics
Gynecology
Hospitalist
Neurology
OB/GYN
Obstetrics
Psychiatry
Radiology
Additional Preceptorships Internal Medicine
Additional Preceptorships Internal Medicine
Additional Preceptorships Internal Medicine
Additional Preceptorships Internal Medicine
Additional Preceptorships Internal Medicine
Additional Preceptorships Internal Medicine
Additional Preceptorships Pediatrics
Additional Preceptorships Pediatrics
Additional Preceptorships Pediatrics
Additional Preceptorships Pediatrics
Additional Preceptorships Dentistry
Additional Preceptorships Dentistry
Type/Field
Type/Field
$

OMB Number 0906-XXXX and Expiration date XX/XX/201X

-

$

-

PreceptingContracts

Page 6

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]
Name of Program:
THC Program Specialty:
Time Period:

0

Residents Salaries and Benefits
Instructions:
Use actual numbers for yout fiscal year reported. Average Annual Salary per FTE refers to the average annual salary for each residency year in the event that
residents within each year are paid differently.
If benefit payments are reported separately from salary, report in the "Average Annual Benefits per FTE" column. Otherwise include in the "Average Annual
Salary per FTE" column.
Report partial salaries as full amount for the period you are reporting for (i.e. if reporting for one year report annual amounts).
For "Chief Residents" row, report FTE, salaries & benefits for Chief Residents that are beyond the final year of training here. For example, if your Chief Residents
are in PGY-3, report their salaries as a PGY-3, leaving the "Chief Residents" row blank.
Add rows if you have more than 7 residents for any given PGY.

Year of Residency
PGY-1
PGY-1
PGY-1
PGY-1
PGY-1
PGY-1
PGY-1
PGY-2
PGY-2
PGY-2
PGY-2
PGY-2
PGY-2
PGY-2
PGY-3
PGY-3
PGY-3
PGY-3
PGY-3
PGY-3
PGY-3
PGY-4
PGY-4
PGY-4
PGY-4
PGY-4
PGY-4
PGY-4
PGY-4
PGY-4
Chief Resident(s)
Chief Resident(s)
Chief Resident(s)
Total

OMB Number 0906-XXXX and Expiration date XX/XX/201X

FTE per resident

Average Annual Salary
per FTE

0.00 $

-

Average Annual
Benefits per FTE

$

Total

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

ResidSalaries

Page 7

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]
Name of Program:
THC Program Specialty:
Time Period:

0

Residency Program Administration Expenses
Residency Administrative Personnel
Instructions:
For Total FTE, include only time that is dedicated to the residency program
For Total Salary and Total Benefits enter the total salary and benefits received by the individual
If benefit payments are reported separately from salary, report in the Total Benefits column. Otherwise include in the Total Salary column.
Cost
Admin Support Salaries

Total Salary

Total FTE

Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Provide Title and Role
Total

0.00 $

Total Benefits

-

$

Residency Program
Cost
$
$
$
$
$
$
$
$
- $
-

Residency Program Explicit Expenses
Instructions:
Please report only those expenses charged directly to the residency program for which this costing instrument applies. In any cases where the residency program is not explicitly charged, please enter "0"
* Do not include expenses reported in other spreadsheets, such as faculty development included in faculty benefits costs or insurance or licensing fees included in clinical operations costs.
Additional Instructions
Please insert the square footage of the space allocated for the residency educational functions

Total Residency Square Footage
Total Amount
Education Costs:
Resident Education Stipends
Resident Required Training
Simulation Center Costs
Education Supplies
Medical/Dental School or OPTI fees
General Educational Allowance
Inpatient Service Costs
Licensing/Certification Fees:
Licensing Examination Fees
In-Service Examination Fees
Board Certification Fees
Board Preparation Costs
Licensing Fees
Program Fees and Costs:
Accreditation Fees
NRMP/Match Participation Fees
Recruitment Costs
Graduation Costs
Faculty/Staff Development
Travel
Away Rotation Housing
General Liability Insurance
Malpractice Insurance
Legal and Accounting
Consortium Expenses (if applicable)
Rent/Occupancy
Supplies:
Mobile Communications Devices
IT Costs
White Coats/Uniforms
Printing and Postage
Office Supplies
Other:
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total Other
Total
Overhead:
Expense Type
Expense Type
Expense Type
Expense Type
Expense Type
Total Overhead

Include fees paid for any resident required training programs, such as ACLS/PALS etc.
Include any costs associated with simulation exersices. These may include cost of simulation equipment, related supplies, or fees to access simulation centers
Educational supplies may include costs associated with library resources, textbooks, journal subscriptions, scholarly association fees, software
Report any fees associated with medical school, dental school or OPTI affiliations
Lump sum amount given to residents for their own purchase of educational supplies and materials
Report any additional inpatient service payments. Do not include any precepting contracts reported in the "Precepting Contracts" spreadsheet.
Include any fees paid for resident licensing exams, such as USMLE fees
Include any fees paid for residents for Board certification exams or training
Include any practice licensing fees paid for residents (not faculty: faculty licenses should be listed under ClinicOps row 18)
Include per program annual assessments and per resident fees for use of any accreditation services
Include any fees paid for participation in the NRMP, AOA, or other match programs
Include any costs associated with recruitment, such as candidate travel, give-a-ways, meals, brochures, etc
Include cost of graduation such as venue, food, entertainment, certificates, etc
Include faculty development costs such as NIPPD, and staff development costs such as conferences, association dues, etc, STFM dues, etc.
Include travel to educational courses and conferences, and any other travel that is paid for by the residency program, except "away rotation housing"
Lodging costs paid by the residency program for away rotations
Include any general liability insurance purchased for the residency program
Only include malpractice insurance if specifically paid for residents or faculty related to residency program activities
Include all legal and accounting fees associated with the residency program
If you have a consortium, include any expenses associated with that consortium that do not appear in any other worksheet
Report only rent or occupancy fees specifically charged to the residency program for residency program space
Include any pagers or cell phones purchased for residents or residency program staff
Only include IT costs charged directly to the residency program, such as laptop computers, e-mail service, or residency program management software for residents

List any expenses not detailed above that are associated with the administration of the residency program. Also include the total for the academic year

$
$

Report any central administrative overhead costs charged to the residency program; Please indicate what your program includes in "overhead cost"

$

OMB Number 0906-XXXX and Expiration date XX/XX/201X

-

ResidAdmin

Page 8

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]
Name of Program:
THC Program Specialty:
Time Period:

0

Residency Program Administration In-Kind Donations
Please include here the value of residency administration costs that you do not have to pay because they are provided for free by other entities.
For example. If your reisdency is housed for free in a location, please estimate and enter below what you would have to pay for square footage, had the residency been required to pay for the space it occupies.
Residency Program Only In-Kind Donations
Instructions:
Please report only those in-kind donations that would have been charged directly to the residency program for which this costing instrument applies. The in-kind donations would be expected to match the "0" items entered in ResidAdmin tab.
Additional Instructions
Total Residency Square Footage
Please insert the square footage of the space allocated for the residency educational functions
Total Amount
Education Costs:
Resident Education Stipends
Resident Required Training
Simulation Center Costs
Education Supplies
Medical/Dental School or OPTI fees
General Educational Allowance
Inpatient Service Costs
Licensing/Certification Fees:
Licensing Examination Fees
In-Service Examination Fees
Board Certification Fees
Board Preparation Costs
Licensing Fees
Program Fees and Costs:
Accreditation Fees
NRMP/Match Participation Fees
Recruitment Costs
Graduation Costs
Faculty/Staff Development
Travel
Away Rotation Housing
General Liability Insurance
Malpractice Insurance
Legal and Accounting
Consortium Expenses (if applicable)
Rent/Occupancy
Supplies:
Mobile Communications Devices
IT Costs
White Coats/Uniforms
Printing and Postage
Office Supplies
Other:
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total Other
Total
Overhead:
Expense Type
Expense Type
Expense Type
Expense Type
Expense Type
Total Overhead

OMB Number 0906-XXXX and Expiration date XX/XX/201X

Include fees paid for any resident required training programs, such as ACLS/PALS etc.
Include any costs associated with simulation exersices. These may include cost of simulation equipment, related supplies, or fees to access simulation centers
Educational supplies may include costs associated with library resources, textbooks, journal subscriptions, scholarly association fees, software
Report any fees associated with medical school, dental school or OPTI affiliations
Lump sum amount given to residents for their own purchase of educational supplies and materials
Report any additional inpatient service payments. Do not include any precepting contracts reported in the "Precepting Contracts" spreadsheet.
Include any fees paid for resident licensing exams, such as USMLE fees
Include any fees paid for residents for Board certification exams or training
Include any practice licensing fees paid for residents (not faculty: faculty licenses should be listed under ClinicOps row 18)
Include per program annual assessments and per resident fees for use of any accreditation services
Include any fees paid for participation in the NRMP, AOA, or other match programs
Include any costs associated with recruitment, such as candidate travel, give-a-ways, meals, brochures, etc
Include cost of graduation such as venue, food, entertainment, certificates, etc
Include faculty development costs such as NIPPD, and staff development costs such as conferences, association dues, etc, STFM dues, etc.
Include travel to educational courses and conferences, and any other travel that is paid for by the residency program, except "away rotation housing"
Lodging costs paid by the residency program for away rotations
Include any general liability insurance purchased for the residency program
Only include malpractice insurance if specifically paid for residents or faculty related to residency program activities
Include all legal and accounting fees associated with the residency program
If you have a consortium, include any expenses associated with that consortium that do not appear in any other worksheet
Report only rent or occupancy fees specifically charged to the residency program for residency program space
Include any pagers or cell phones purchased for residents or residency program staff
Only include IT costs charged directly to the residency program, such as laptop computers, e-mail service, or residency program management software for residents

List any expenses not detailed above that are associated with the administration of the residency program. Also include the total for the time period this worksheet applies to.

$
$

Report any central administrative overhead costs paid by others but would normally be charged to the residency program; Please indicate what your program includes in "overhead cost"

$

-

In-kind ResidAdmin

Page 9

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]

Name of Program:
THC Program Specialty:
Time Period:

0

Clinic Administrative Expenses: Include all clinic administrative costs that are not included as part of the residency admin tab or as part of overhead
Instructions:
Enter expenses matched to the total medical or dental visits, revenue, and clinic operation expenses reported for the resident continuity clinic site
Include all clinic administrative costs that are not included as part of the residency admin tab or as part of overhead
Do not include expenses reported in other spreadsheets. For example, do not report here malpractice insurance or licensing fees reported in the residency admin expenses.
In the "Inpatient Service" column, report any administrative costs allocated to the inpatient service.

Costs
Residency
Continuity Clinic
Site
Administrative Personnel Salaries/Benefits
Purchased Admin Services
Office Supplies
Recruitment
Staff Development
Travel
IT Infrastructure
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total Other
Total Clinic Admin Expenses
Overhead
Administrative Overhead
Finance and Accounting Overhead
Physical Plant
IT Overhead
Other Expense Type
Other Expense Type
Other Expense Type
Total Other
Total Overhead

Inpatient Service (if
applicable)
Additional Instructions:
Include any contracts for administrative type services for the clinic only
Include the cost of clinic office supplies
Include any additional recruitment costs that are separate from the residency recruitment costs
Include any non-residency, clinic staff development costs
Include any travel associated with clinical activities
Include any hardware, wiring, servers etc purchased in the last full academic year
Include the name and amount of any other expenses that are not duplicative

$
$

- $
- $

$
$

N/A
N/A
N/A
N/A
N/A
N/A
N/A
- N/A
- N/A

OMB Number 0906-XXXX and Expiration date XX/XX/201X

Report any additional centralized overhead costs here that were not reported elsewhere
This may include your organization's CEO, CFO, COO, CNO, CMO, etc
This may include your organization's finance office, billing office, accounting fees, payroll office, etc
Include any maintenance, mortgage, repairs, etc. that are allocated as overhead to the residency continuity clinic site.
Usually includes IT department staff
List the name and amount of any other overhead categories that are allocated to the residency continuity clinic site

ClinicAdmin

Page 10

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]

Name of Program:
THC Program Specialty:
Time Period:

0

Clinical Operations Expenses: Enter expenses matched to the total medical or dental visits, revenue, and clinic administration expenses reported for the resident continuity clinic site.
Instructions:
Enter expenses matched to the total medical or dental visits, revenue, and clinic administration expenses reported for the resident continuity clinic site
Do not include expenses reported in other spreadsheets. For example, do not include malpractice insurance or licensing fees reported in the residency admin expenses.
Additional Instructions:
Insert the total Clinic square footage of the Family Medicine Center, NOT including any residency/educational space.

Clinic Square Footage
Total Amount
Clinical Support Personnel Salaries/Benefits
Purchased Medical/Dental Services
Medical/Dental Supplies
Medical/Dental Equipment
Licensing Fees
Malpractice Insurance
EHR licenses/maintenance
Uniforms
Occupancy
Depreciation
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total Other
Total

Purchased medical services are contracted clinical services that are not accounted for in any other category
Include any medical/dental supplies for patient care services in the residency continuity clinic
Include any medical/dental equipment purchasing or maintenance costs of that medical equipment
Include any licensing fees of the actual clinical site or of faculty, providers and staff working at that site
Include any malpractice costs above and beyond FTCA coverage, if applicable. Please do not duplicate malpractice insurance expenses
provided in ResidAdmin in cell C55
If EHR licenses are a one time fee, just insert maintenance costs here. If licenses are paid annually, include license and maintenance fees
Include the cost of staff uniforms, white coats, scrubs, etc
Include any rent, building maintenance, or utilities costs not explicitly reported elsewhere.
Include equipment or facility depreciation for any items not reported in line 17 "Medical/Dental Equipment" above.
Report the name and amount of any other expenses not listed above.

$
$

OMB Number 0906-XXXX and Expiration date XX/XX/201X

-

ClinicOps

Page 11

Evaluation and Initial Assessment of the HRSA Teaching Health Centers Graduate Medical Education Program
The George Washington University
Principal Investigator: Marsha Regenstein [email protected]
Name of Program:
THC Program Specialty:
Time Period:

0

Residency Start-Up Expenses
Instructions:
Please complete this worksheet if your residency program accepted its first class of residents in 2010 or later
Include all costs associated with the start-up phase of your residency program. These are costs expended prior to the start of your
residency program. Do not report any costs here that are already reported as expenses in other worksheets in this workbook.
If benefit payments are reported separately from salary, report in the Benefits row. Otherwise include in the Personnel costs.

Start up Expenses
Personnel
Program Director
Residency Program Coordinator
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Sub-total
Benefits
Total
Contracts
Legal
Consultants
Grantwriter
Faculty hours
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total Contracts

Total Amount

Additional Instructions

$
$

-

$

-

$

-

$

-

Non-Wage
Accreditation Application Fee
Faculty Recruitment
Faculty Development
IT Costs
Office Supplies
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total Non-Wage

$

-

TOTAL

$

-

Capital
Capital Improvements
Equipment
Furnishings
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total Capital

Include any additional faculty recruitment costs above prior provider recruitment costs required to start the residency program
Include any initial faculty development costs prior to the start of the residency program
Include any initial IT infrastructure costs to support the new residency program. This may include hardware or software costs.

Include only those capital investments made specifically to support the residency program. For example, renovations for residency offices or teaching space.

$

OMB Number 0906-XXXX and Expiration date XX/XX/201X

-

StartUp

Page 12