Annual Cost Analysis - clinic

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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 _______________________)
$__________
__________ %
__________ %