Annual Cost Analysis - clinic

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Cooperative Re-Engagement Controlled Trial (CoRECT)

Attachment #13e

Annual Implementation Costs for CoRECT-CLINIC COSTS

Public reporting burden of this collection of information is estimated to average 1.5 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-New)

		Appendix 13 e: Annual Implementation Costs for CoRECT-CLINIC COSTS				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. Out-of-care list generation

2. Re-engagement/handoff to clinic

3. Administration time

4. Clinic staff salaries

Clinical 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.

	Description	Responsible staff (ex. nurse, data manager, physician)	Frequency Count/Week, Month b	Total Time Spent (hr)b
(1) Out-of-care lists
Generate surveillance line list	Create initial OOC list using missed appointment data		_______/_____
Match with HD list	Time spent reconciling health department and clinic OOC list		_______/_____
Communicate with HD-data transmission (initial)	Transmit reconciled OOC list back to HD prior to case conference		_______/_____
Case Conference	Time clinic staff spent participating in case-conference to complete OOC list		_______/_____

(2) Re-engagement/ handoff to clinic	Description	Responsible staff (ex. nurse, data manager, physician)	Frequency Count/Week, Month b	Total Time Spent (hr)b
Staff time spent contacting OOC patients	Appointment reminders, missed visit contacts, support service contacts		_______/_____
Follow-up with health department	Time spent communicating with DIS/field epi to schedule re-engaged patients for medical or phlebotomy visits		_______/_____

(3) Administration Time	Responsible staff (ex. clinic nurse, physicians, 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}

(4) Clinic program staff salary
Clinics Staff	Annual salary (exclude fringe)	Fringe benefit (%)	% time spent in this project
Clinic Physician	$__________	__________ %	__________ %
Clinic data manager	$__________	__________ %	__________ %
Clinical nurse coordinator	$__________	__________ %	__________ %
	$__________	__________ %	__________ %
Others (specify _____________________)	$__________	__________ %	__________ %
Others (specify _______________________)	$__________	__________ %	__________ %
Others (specify ______________________)	$__________	__________ %	__________ %
Others (specify _______________________)	$__________	__________ %	__________ %

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