Revised Clinic Cost Form

Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care

Att 12_Clinic Cost Form_OMB comments_KB_clean copy

Clinic Staff Cost Form

OMB: 0920-1019

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Attachment 12


Form Approved

OMB No: 0920-1019

Exp. Date: XX/XX/XXXX






Integrating Community Pharmacists and Clinical Sites

for Patient-Centered HIV Care



Attachment 12 Clinic 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)


Clinic Cost Form


Clinic project activities for physicians, nurse practitioners and physician assistants

Staff ID

Time spent

Time spent


(minute/patient)

(hour/week)







Recruitment activities




Discussing project with patients, other recruitment activities

_________

___ min/pt encounter or

_____ hr/week







Preparing for Patient Encounters




Reviewing MTM documentation and pharmacists' recommendations

_________

___ min/pt encounter or

_____ hr/week

Other preparation (specify): _____________________________

_________

___ min/pt encounter or

_____ hr/week







Time spent with patients




Medication therapy follow-up with patients

_________

___ min/pt encounter or

_____ hr/week

Checking and verifying date/time of patients' follow-up MTM sessions

_________

___ min/pt encounter or

_____ hr/week

Other patient interactions (specify): ______________________________

_________

___ min/pt encounter or

_____ hr/week







Time spent interacting with pharmacists




Discussing medication therapy/action plans/adherence (via phone, email, fax, in-person etc.)

_________

___ min/pt encounter or

_____ hr/week










Project related meetings




With clinic staff


_________

___ min/pt encounter or

_____ hr/week

With pharmacy staff


_________

___ min/pt encounter or

_____ hr/week







Time spent on documentation




Filling out Initial or Interim Patient Information forms

_________

___ min/pt encounter or

_____ hr/week

Data entry and transmission

_________

___ min/pt encounter or

_____ hr/week

Data management


_________

___ min/pt encounter or

_____ hr/week

Data quality assurance

_________

___ min/pt encounter or

_____ hr/week







Other activities

_________

___ min/pt encounter or

_____ hr/week

(Specify): ______________________________________

_________

___ min/pt encounter or

_____ hr/week

(Specify): ______________________________________

_________

___ min/pt encounter or

_____ hr/week

(Specify): ______________________________________

_________

___ 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.



Clinic activities for project supervision and general administration

Staff ID

Time spent

Time spent


(minute/patient)

(hour/week)







Project supervision





(Specify): ______________________________________

_________

___ min/pt encounter or

_____ hr/week

(Specify): ______________________________________

_________

___ min/pt encounter or

_____ hr/week

(Specify): ______________________________________

_________

___ min/pt encounter or

_____ hr/week













General administration




(Specify): ______________________________________

_________

___ min/pt encounter or

_____ hr/week

(Specify): ______________________________________

_________

___ min/pt encounter or

_____ hr/week

(Specify): ______________________________________

_________

___ min/pt encounter or

_____ hr/week











Other activities

_________

___ min/pt encounter or

_____ hr/week

(Specify): ______________________________________

_________

___ min/pt encounter or

_____ hr/week

(Specify): ______________________________________

_________

___ min/pt encounter or

_____ hr/week

(Specify): ______________________________________


___ min/pt encounter or

_____ hr/week

 

 

 


 

 



Clinic program staff salary:









Service Unit

 

Staff ID

Annual salary (exclude fringe)

Fringe benefit (%)

% time spent in this project

Physician


________

$__________

__________ %

__________ %

Nurse Practitioner


________

$__________

__________ %

__________ %

Physician's Assistant


________

$__________

__________ %

__________ %

Nurse


________

$__________

__________ %

__________ %

Case Manager/Social Worker

________

$__________

__________ %

__________ %













Others (specify __________________________)

________

$__________

__________ %

__________ %

Others (specify __________________________)

________

$__________

__________ %

__________ %

Others (specify __________________________)

________

$__________

__________ %

__________ %

Others (specify __________________________)

________

$__________

__________ %

__________ %







<list each clinic staff working on project> Add rows as necessary

 

 

 



Training







Please list each staff person who attended 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:







Clinic office/facility space


________

sq feet

$_______









Utilities:







Telephone (local, long distance)




_______


Internet





_______









Other (specify):______________




_______


Other (specify):______________




_______


Other (specify):______________




_______


Other (specify):______________




_______


 

 

 

 

 

 

 




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