Start up cost analysis - health dept

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Cooperative Re-Engagement Controlled Trial (CoRECT)

Attachment #13b

Start-up Costs for CoRECT

Health Department

Public reporting burden of this collection of information is estimated to average 1 hour 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-New)

		Appendix 13b: Start-up Costs for CoRECT Health Department				Rev: 01/18/2015
Site name: _______________________________________				Completed Date: _________________
Data collection period (MM/DD/2016 -- MM/DD/2018)

The attached cost analysis worksheets are designed to determine how much it costs to implement the intervention that reengages those who are determined out of care respectively - the worksheets will:

- Systematically list the resources needed to implement the CoRECT Study

- Itemize the amount (quantity) of each of the resources used

- Assign dollar values to the resources

The worksheets contain fields for several cost categories listed below. The data will be used to determine the total start-up program costs.

1. Pre-implementation training

2. Out-of-care list generation

3. DIS activities

4. Administration time

5. Office supplies

6. Staff salaries

Sites may update (insert rows) and clarify cost categories and the items listed under each of the cost categories, based on the retention in care project activities performed at that specific site. The data should reflect actual cost or resources allocated under this project, however, some of the data elements may require estimation of costs or resources used based on available information. In such cases, sites may use appropriate data sources or separate calculation to complete the forms.

Evaluation costs that are strictly research-related (e.g., ACASI software, incentives for completing ACASI) should NOT be included in this exercise. However, all resources that are used for project implementation purposes should be included, even if those go beyond specific project funds.

(1) Pre-implementation/ training	Staff (ex. study coordinator, DIS, data manager)	Training period (days) mmdd-mmdd	Time spent per day	Per diem
Person 1
Person 2
Person 3
Person 4
Person 5
Training related travel	Staff (ex. study coordinator, DIS, data manager)	Time spent on travel (hrs)	Mileage (mile)	Other costs ($)a

^{a Include offsite/out-of-state training: parking, taxi fare, and miscellaneous costs, if applicable}

(2) Out-of-care lists	Description	Responsible staff (ex. study coordinator, DIS, data manager)ac	Frequency Count/Week, Month bc	Total Time Spent (hr)b
Generate surveillance line list	Create initial OOC list using surveillance data	_______________	_______/_____ _______/_____ _______/_____
Match with clinic list	Time spent reconciling health department and clinic OOC list	_______________	_______/_____ _______/_____ _______/_____
Communicate with clinic-data transmission (initial)	Transmit reconciled OOC list back to clinic prior to case conference	_______________	_______/_____ _______/_____ _______/_____
Health department preliminary investigation	How much time spent HD staff spent determining if OOC patients are deceased, out of jurisdiction, incarcerated etc	_______________	_______/_____ _______/_____ _______/_____
Case Conference	Time HD staff spent participating in case-conference to complete OOC list	_______________	_______/_____ _______/_____ _______/_____
Communicate with clinic-data transmission (final)	Transmit final OOC list back to clinics prior to case conference	_______________	_______/_____ _______/_____ _______/_____
Data entry of final list	Time spent entering OOC patient data into system to transfer to field epidemiologists/disease intervention specialist	_______________	_______/_____ _______/_____ _______/_____

^{a List multiple staff if applicable; labor cost could be calculated based on median wage or directly from the activity log data.}

^{b Data in this column reflect the aggregate over the data collection period, e.g., week or month c Fill out a separate line (staff and hours) for any staff involved in this item}

(3) DIS Activities	Description	Responsible staff (ex. study coordinator, DIS, data manager) a	Frequency Count/Week, Month b	Total Time Spent (hr)b
Records review	Time spent reviewing OOC patient records prior to initiating		_______/_____
Outreach to locate and contact OOC patients	Time spent to contact OOC patients including phone calls, databases, in-person visits		_______/_____
Out of care interview/barriers to care survey	Initial interview with OOC patients to assess why have not returned to HIV medical care		_______/_____
Engagement assistance	Activities that assist in re-engagement (ie ARTAS intervention)		_______/_____
Follow-up with clinics	Time spent communicating with clinics to enable clinic or phlebotomy visits		_______/_____
Follow-up engagement assistance	Transition to Care-Activities to complete patient hand-off with-in one week of patient re-linkage visit.		_______/_____
Documentation of engagement assistance into database	Time spent entering activities conducted to engage OOC patients and re-link to clinics for HIV medical care		_______/_____

^{a List multiple staff if applicable; labor cost could be calculated based on median wage or directly from the activity log data.}

^{b Data in this column reflect the aggregate over the data collection period, e.g., week or month.}

(4) Administration Time	Responsible staff (ex. study coordinator, DIS, data manager) ac	Frequency Count/Week, Month bc	Total Time Spent (hr)b
Project-related meetings	_______________	_______/_____ _______/_____ _______/_____
Data management	_______________	_______/_____ _______/_____ _______/_____
Quality assurance checks	_______________	_______/_____ _______/_____ _______/_____
General administrative duties	_______________	_______/_____ _______/_____ _______/_____
Project supervision	_______________	_______/_____ _______/_____ _______/_____
Other (specify): __________________	_______________	_______/_____ _______/_____ _______/_____
Other (specify): __________________	_______________	_______/_____ _______/_____ _______/_____

^{a List multiple staff if applicable; labor cost could be calculated based on median wage or directly from the activity log data.}

^{b Data in this column reflect the aggregate over the data collection period, e.g., week or month c Fill out a separate line (staff and hours) for any staff involved in this item}

(5) 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)______________			________		$________		$________
(6) Health Department Staff		Annual salary (exclude fringe)		Fringe benefit (%)		% time spent in this project
Surveillance Coordinator		$__________		__________ %		__________ %
Data manager		$__________		__________ %		__________ %
DIS		$__________		__________ %		__________ %
CoRECT Study Coordinator		$__________		__________ %		__________ %
Others (specify _____________________)		$__________		__________ %		__________ %
Others (specify _______________________)		$__________		__________ %		__________ %
Others (specify ______________________)		$__________		__________ %		__________ %

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