Revised Pharmacy Cost Form

Attachment 13

Form Approved

OMB No: 0920-1019

Exp. Date: XX/XX/XXXX

Integrating Community Pharmacists and Clinical Sites

for Patient-Centered HIV Care

Attachment 13 Pharmacy Cost Form

Public reporting burden of this collection of information is estimated to average 10 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-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1019)

Pharmacy Cost Form

Pharmacy project activities for pharmacists, technicians and support staff			Staff ID	Time spent	Time spent
				(minute/patient)	(hour/week)
Recruitment activities
Discussing project with patients, other recruitment activities			ID = _______	___ min/pt encounter or	_____ hr/week
Preparing for Patient Encounters
Reviewing medical record documentation and developing RPh recommendations			ID = _______	___ min/pt encounter or	_____ hr/week
Other preparation (specify): _____________________________			ID = _______	___ min/pt encounter or	_____ hr/week
Time spent with patients
Medication therapy management session			ID = _______	___ min/pt encounter or	_____ hr/week
Checking and verifying date/time of patients' follow-up MTM sessions			ID = _______
Other patient interactions (specify): ______________________________			ID = _______	___ min/pt encounter or	_____ hr/week
Time spent interacting with prescribers
Discussing medication therapy/action plans/adherence (via phone, email, fax, in-person etc.)			ID = _______	___ min/pt encounter or	_____ hr/week
Project related meetings
With clinic staff			ID = _______	___ min/pt encounter or	_____ hr/week
With pharmacy staff			ID = _______	___ min/pt encounter or
Time spent on documentation
Filling out Initial or Interim Patient Information forms			ID = _______	___ min/pt encounter or	_____ hr/week
Data entry and transmission			ID = _______	___ min/pt encounter or	_____ hr/week
Other activities			ID = _______	___ min/pt encounter or	_____ hr/week
(Specify): ______________________________________			ID = _______	___ min/pt encounter or	_____ hr/week
(Specify): ______________________________________			ID = _______	___ min/pt encounter or	_____ hr/week
(Specify): ______________________________________			ID = _______	___ min/pt encounter or	_____ hr/week
How many project patients did you serve this week?* _____________
*include all aspects of model care--in-person encounters, encounters via phone, pharmacy site interactions etc.

Pharmacy program staff salary:
Service Unit		Staff ID		Annual salary (exclude fringe)	Fringe benefit (%)	% time spent in this project *
Pharmacist		ID =_______		$__________	__________ %	__________ %
Technician		ID = _______		$__________	__________ %	__________ %
Support Staff		ID = _______		$__________	__________ %	__________ %
Pharmacy Management		ID = _______		$__________	__________ %	__________ %
District or above Management		ID = _______		$__________	__________ %	__________ %
Others (specify __________________________)		ID = _______		$__________	__________ %	__________ %
Others (specify __________________________)		ID = _______		$__________	__________ %	__________ %
Others (specify __________________________)		ID = _______		$__________	__________ %	__________ %
Others (specify __________________________)		ID = _______		$__________	__________ %	__________ %
<list each clinic staff working on project> Add rows as necessary

Training
Please list each staff person who attended the clinic training
Training		Staff ID	Training date	Training period	Per diem	Air fare
			Month/Year	(days)	($)	($)
Person 1		__________	__________	__________	__________	__________
Person 2		__________	__________	__________	__________	__________
Person 3		__________	__________	__________	__________	__________
Person 4		__________	__________	__________	__________	__________
<list each staff person attending>
Office supplies and materials
Description			Quantity	Unit		Monthly total
				cost ($)		Cost ($)
Office supplies/stationeries		__________	________	________		________
Printed material provided to patients		__________	________	________		________
Appointment reminder cards		__________	________	________		________
Postage		__________	________	________		________
Calendar/day planner		__________	________	________		________
File folder/organizers		__________	________	________		________
Translation of materials		__________	________	________		________
Posters, brochures		__________	________	________		________
Other (specify)______________		__________	________	________		________
Other (specify)______________		__________	________	________		________
Other (specify)______________		__________	________	________		________
Other (specify)______________
Durable material/Equipment cost
Data from this section will be used to estimate the annual cost of durable items. 'Unit cost' may be based on the estimated remaining value of the item purchases previously, or the purchase price if it is new.
Description		Quantity	Unit	Remaining		% used, for
			cost ($)	useful life (year)		this project
Desktop computer		________	_______	_______		_______
Laptop computer		________	_______	_______		_______
Furniture		________	_______	_______		_______
Other (e.g., cell phone, pager)
specify: ______________________		________	_______	_______		_______
specify: ______________________		________	________	________		________
specify: ______________________		________	________	________		________
specify: ______________________		________	________	________		________
Facility space and utilities
Because of the difficulty in obtaining these data, the sites may report the following data at the minimum, but they may report additional information as much as available.
Description					Monthly total
					Cost ($)
Office space:
Pharmacy office/facility space			________	sq feet	$_______
Utilities:
Telephone (local, long distance)					_______
Internet					_______
Other (specify):______________					_______
Other (specify):______________					_______
Other (specify):______________					_______
Other (specify):______________					_______