Clinic Cost Form

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

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):______________					_______

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)