Human Trafficking Evaluation Cost Module/Human Trafficking Evaluation Labor Module (A-6)

This questionnaire should be completed by the program director at your organization with assistance and oversight from staff members knowledgeable about the resource use and costs for the program, as designated by the program director.

The questionnaire is designed to collect resource use and cost information pertaining to your human trafficking program for a completed fiscal year.

Before you begin, please note:

The purpose of providing data on resource use and cost information is to better understand the costs of responding to trafficking victims, and the labor, other direct, and indirect costs of key services;
These data will be used to inform future program development and evaluation and provide information for ongoing program improvement to Family and Youth Services Bureau (FYSB) grantees;
We estimate it will take about 1 hour for you to complete this instrument;
Providing these data are voluntary; and
These data will be kept private to the extent permitted by law; and
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. The OMB number for this information collection is 0970-XXXX and the expiration date is XX/XX/20XX.

Please complete Sections A through J of this questionnaire, following the detailed instructions provided. To complete the questionnaire, please use expenditure reports rather than budgets, because budgets do not always coincide with actual resource use.

The information provided in this questionnaire, or through any other part of this study, will be held private and will not be reported in a way that could directly identify you or your program.
Thank you for your participation!

If you have any questions about the questionnaire, please contact:

XXXXX.XXXXX

RTI International

1-919-990-8345

[email protected]

A. Fiscal Year

The information given in this questionnaire should be for your program’s last fiscal year for which you have complete records. Please indicate below the calendar dates for the fiscal year to which the data in this module correspond.

The data in this questionnaire are for fiscal year……………______________ to _____________

(Month/Year) (Month/Year)

Throughout this questionnaire, please answer all questions as they pertain to your human trafficking program for the above time period (referred to as “the previous fiscal year”) unless otherwise indicated.

B. Organization Characteristics

This section collects information on the characteristics of your organization for which we are collecting resource use and cost data.

B1. Is this organization part of a larger program/agency/corporation (i.e., a parent organization)?

Yes

Don’t Know

B2. Which type of organization/agency is this? (Please check all that apply.)

Private for-profit

Private nonprofit

State government

Local, county, or community government

Tribal government

Federal government

Other (please specify): _____________________________

B3. For which types of clients are human trafficking services provided? (Please check all that apply.)

Adolescents

Clients with co-occurring mental health and substance abuse disorders

Criminal justice clients

Seniors or older adults

Adult women

Adult men

Other (please specify): _____________________________

B4. What is your job position within this organization?

Program/facility director

Clinical staff

Administrative staff

Medical director

Chief business officer (CBO) or chief executive officer (CEO)

Chief financial officer (CFO)

Other (please specify): ____________________________

C. Client Information

This section collects information on the number of human trafficking clients that your program served in the previous fiscal year.

From this point on, unless otherwise indicated, your answers should pertain to your human trafficking program within your organization.

C1. What was your human trafficking program’s average daily census (i.e., the average number of people enrolled in services at a given point in time) during the fiscal year?

Daily Census: ________ clients

C2. What were the total new admissions to your human trafficking program in the fiscal year?

New Admissions: ________ clients

C3. What was your human trafficking program’s actual capacity (physical capability) at the end of the fiscal year?

Actual Capacity: ________ clients

C4. How many clients visit your human trafficking program on a typical day?

________ clients

D. Personnel

This section collects information on the labor resources used by your human trafficking program during the previous fiscal year (as defined on page 1 of this questionnaire). This section is divided into four parts: (1) paid employees, (2) contracted employees, (3) volunteer workers, and (4) any other labor costs.

Important Reminder: In completing this questionnaire, please obtain this information from expenditure reports as opposed to budgets, because budgets do not always coincide with actual resource use.

1. Paid Employees

D1. What was the total labor expense (excluding all fringe benefits and payroll taxes) for paid employees at your human trafficking program in the previous fiscal year? Please do not include the costs for contracted employees.

$_______________per year for paid employees

D1a. For the previous fiscal year, which of the following fringe benefit expenses did your human trafficking program incur for your paid employees? Please report total annual expenses for each category.

a.	Health Insurance	$_____________
b.	Pension and Retirement	$_____________
c.	Disability	$_____________
d.	Vacation	$_____________
e.	Sick Leave	$_____________
f.	Other (please specify):
	_____________________	$_____________
	_____________________	$_____________
g.	TOTAL Fringe Benefit Expenses	$_____________

D1b. For the previous fiscal year, which of the following payroll tax expenses did your human trafficking program incur for your paid employees? Please report total annual expenses for each category.

a.	FICA (Federal Insurance Contributions Act)	$_____________
b.	Federal and/or State Unemployment Insurance	$_____________
c.	Worker’s Compensation	$_____________
d.	Other (please specify):
	_____________________	$_____________
	_____________________	$_____________
e.	TOTAL Payroll Tax Expenses	$_____________

2. Contracted Employees

If your human trafficking program had a contract with a person to provide a service (e.g., a medical doctor), then enter this information in Question D2 below. If your program had a contract with a company/corporation to provide a service, then enter this information in Question E1 on page 9.

EXAMPLE: If you had a contract in the previous fiscal year with Dr. Smith to perform intake medical exams at your organization for your human trafficking program, then you would include the cost of his services in Question D2 below. However, if laboratory tests (e.g., HIV testing) were done by Company XYZ that is under contract with your program, then you would include the cost to your program for these lab services under Contracted Services on page 9.

D2. For the previous fiscal year, for which of the following contracted employees did your human trafficking program incur expenses? Please report total annual expenses for each category.

a.	Doctor(s)	$_____________
b.	Pharmacist(s)	$_____________
c.	Attorney(s)	$_____________
d.	Accountant(s)	$_____________
e.	Other (please specify):
	_____________________	$_____________
	_____________________	$_____________
f.	TOTAL Contracted Employee Costs	$_____________

3. Volunteer Workers

D3. Does your human trafficking program use volunteer workers in providing services or in performing administrative activities in support of services?

Yes

Go to Question D4

Don’t Know

D3a. For each volunteer worker (if any) that provided services to your human trafficking program in the previous fiscal year, please list

their job type or position (Column A),

their total hours worked at your program during the previous fiscal year (Column B), and

the estimated cost per hour for each position if you had to pay for them (Column C).

Please refer to the example on line 1 below to help you in providing the appropriate information.

Volunteers	A. Job Type/Position	B. Total Volunteer Hours	C. Estimated Cost per Hour ($)
Example	Degreed Counselor	1,000	$15.00
Volunteer 1			$
Volunteer 2			$
Volunteer 3			$
Volunteer 4			$
Volunteer 5			$
Volunteer 6			$
Volunteer 7			$
Volunteer 8			$
Volunteer 9			$
Volunteer 10			$

4. Any Other Labor Costs

D4. Questions D1 through D3 should have captured all of the labor costs for your human trafficking program. Do you have any other labor costs that your program incurred during the previous fiscal year that are not captured above?

Yes

Go to Question E1

Don’t Know

D4a. Please provide any additional labor costs here.

$__________ Total Other Labor Costs

D4b. If possible, please indicate the types of costs included in these other labor costs.

(Specify: ___________________________________)

E. Contracted Services

If your human trafficking program had a contract with a company/corporation to provide a service, then enter that information in Question E1 below. If your program had a contract with a person to provide a service, then that information should have been entered in Question D2 in the previous section.

EXAMPLE: If laboratory tests (e.g., HIV testing) are done by Company XYZ that is under contract with your program, then you would include the cost to your program for these lab services in Question E1 below. However, if you have a contract with Dr. Smith to perform intake medical exams at your organization for your human trafficking program, then you would include the cost of his services in Question D2 on page 6.

E1. For the previous fiscal year, for which of the following services did your human trafficking program have a contract with a company/corporation? Please report total annual expenses for each category.

a.	Medical	$_____________
b.	Pharmacy	$_____________
c.	Laboratory	$_____________
d.	Legal	$_____________
e.	Accounting	$_____________
f.	Security	$_____________
g.	Computer	$_____________
h.	Advertising	$_____________
i.	Repair and Maintenance	$_____________
j.	Pest Control	$_____________
k.	Housekeeping	$_____________
l.	Other (please specify):
	_____________________	$_____________
	_____________________	$_____________
m.	TOTAL Contracted Services Costs	$_____________

F. Buildings and Facilities

This section collects information on the value of the building space used by your human trafficking program during the previous fiscal year.

F1. What were your total expenditures (e.g., rent or mortgage payments) for the space used by your human trafficking program during the previous fiscal year? If the building space was jointly used with another program or used for other services besides human trafficking services, please prorate the amount to reflect the portion of space costs incurred by your human trafficking program only.

$_________

F2. How large was the space in all the buildings used by your human trafficking program during the previous fiscal year? If building space was jointly used with another program or used for other services besides human trafficking services, please prorate the amount of space to reflect the portion of the total space used by your human trafficking program only.

__________ square feet

F3. Do your expenditures for the space used by your human trafficking program accurately reflect the current market value of the space?

Yes 1  (Go to G1)

No……………………… 2 (Space is provided “free” or at a subsidized rate)

F4. What would you estimate your total expenditures on space would have been in the previous fiscal year if you had paid fair market value for the space?

$_________

Don’t Know

G. Depreciation

G1. For the previous fiscal year, for which of the following capital items did your human trafficking program have depreciation expenses? Please report total annual expenses for each category.

a.	Building (not included in rent/mortgage expense)	$_____________
b.	Vehicles	$_____________
c.	Furniture	$_____________
d.	Equipment	$_____________
e.	Security Systems	$_____________
f.	Computers	$_____________
g.	Other (please specify):
	_____________________	$_____________
	_____________________	$_____________
h.	TOTAL Depreciation Costs	$_____________

H. Supplies, Materials, and Minor Equipment

H1. Please list the total cost for supplies, materials, and minor equipment used by your human trafficking program in the previous fiscal year. Please report total annual expenses for each category.

a.	Drugs and Pharmacy (please specify)
	_____________________________	$__________
	_____________________________	$__________
	_____________________________	$__________
	_____________________________	$__________
	_____________________________	$__________
b.	Laboratory Supplies	$__________
c.	Medical Supplies	$__________
d.	Office Supplies	$__________
e.	Housekeeping Supplies	$__________
f.	Minor Equipment (e.g., computers, furniture not including depreciation costs)	$__________
g.	Dietary—Food	$__________
h.	Other Supplies	$__________

i.	TOTAL Supplies and Materials Costs	$__________

I. Miscellaneous Resources and Costs

I1. What was the cost of other miscellaneous items used by your human trafficking program in the previous fiscal year? Please report total annual expenses for each category.

a.	Utilities (e.g., electricity, gas, oil, water and sewer, garbage)	$__________
b.	Insurance (e.g., liability, malpractice, director and officers)	$__________
c.	Non-Payroll Taxes (e.g., federal, state, local)	$__________
d.	Communications (e.g., telephone, postage, printing and duplicating, advertising, publications)	$__________
e.	Client Transportation (e.g., providing clients transportation to and from services; subsidizing client costs for public transportation to and from services)	$__________
f.	Dues, Memberships, and Fees	$__________
g.	Staff Training	$__________
h.	Staff Traveling	$__________
i.	Any other costs not yet accounted for in this questionnaire	$__________
j.	TOTAL Miscellaneous Costs	$__________

J. Administrative Overhead

This section collects information on an administrative overhead rate that may have been applied to your grants (federal or local), contracts, or other funding sources. Usually, overhead rates are used to pay for administrative services that occur at the level of the parent organization, hospital, or program for which your human trafficking program receives benefit but does not pay for directly (e.g., marketing, outreach, business office, billing).

J1. Is there a standing overhead rate or administrative charge that is incurred by your human trafficking program?

Yes

No  Thank you for your participation.

J2. Have you included this overhead rate/administrative charge in the cost information you have already provided in this questionnaire (in Sections D through I)?

Yes

J3. What is the overhead rate (or administrative charge)?

a. Overhead Rate: ________%

b. Administrative Charge: $__________

J4. To which cost component is this overhead rate (or administrative charge) applied?

Yes



a. Labor Costs

b. Total Costs

c. Other (please specify)

(Specify: ___________________________________)

J5. If possible, please indicate the resources provided to your human trafficking program with this overhead money (e.g., billing, payrolls, marketing, legal services, other administrative tasks):

a. (Specify: ___________________________________)

b. (Specify: ___________________________________)

c. (Specify: ___________________________________)

d. (Specify: ___________________________________)

THANK YOU FOR YOUR PARTICIPATION.

Human Trafficking Evaluation

Labor Module

RTI International

Research Triangle Park, NC 27709

January 2015

Date Completed: ___________/_____________/____________

ORGANIZATION ID# __________

This instrument is derived from the Substance Abuse Services Cost Analysis Program developed at and copyrighted by RTI International.

Table of Contents

Section Page

Introduction A-6.20

A. Time Allocation A-6.21

B. Weekly Service Provision A-6.26

Introduction

This questionnaire should be completed by the program director or other senior manager who is familiar with the day-to-day operations and services delivered at your human trafficking program. Assistance from other program staff as needed is strongly encouraged.

Although your program may be part of a larger organization or provide other services besides human trafficking services, throughout this questionnaire, please answer all questions as they pertain to your human trafficking program.

This questionnaire collects information on the labor resources used in an average or typical week over the past month by your human trafficking program to provide human trafficking services and perform activities associated with treatment provision.

The questionnaire is divided into three sections:

Section A: Time Allocation. You are asked to provide information on the time spent in an average or typical week over the past month by your program’s employees, contracted personnel, and volunteer workers providing specific client services or performing specific activities associated with providing human trafficking services.

Section B: Weekly Service Provision. For selected client services, you are asked to provide information on the average number of services provided by staff in an average or typical week over the past month, and the average length of time per session for these services.

Section C: Labor Wage Rates. You are asked to provide information on hourly wage rates for your current staff for whom you report time in Section A.

The information provided in this questionnaire, or through any other part of this study, will be held private and will not be reported in a way that could directly identify you or your program.

Thank you for your participation!

If you have any questions about the questionnaire, please contact:

XXXX.XXXXX

RTI International

1-919-990-8345

[email protected]

A. Time Allocation

In this section, we are requesting information on the time spent in an average or typical week over the past month by your staff. For the purposes of this study, we define a week to be 7 consecutive days. We are collecting this information by asking that you complete the three Time Allocation Tables for (1) non-medical direct care staff, (2) medical staff, and (3) management and administrative staff.

Step-by-Step Instructions:

1. Column 2: Record the total number of employees, contracted personnel, and volunteer workers at your program that are in each of the job positions listed.

For example, if your human trafficking program has 2 social workers (MSW) that provide services, then you would indicate “2” in Column 2 of the Time Allocation Table for Non-Medical Direct Care Staff. See example provided in first row of the Time Allocation Table for Non-Medical Direct Care Staff.

For example, if your human trafficking program has 3 physicians that provide services, then you would indicate “3” in Column 2 of the Time Allocation Table for Medical Staff. See example provided in first row of the Time Allocation Table for Medical Staff.

2. Column 3: Record the total hours worked per week by all staff indicated in Column 2 for each job position.

For example, if the 2 social workers listed in Column 2 each work 30 hours per week for your human trafficking program, then you would indicate “60 hours” in Column 3 of the Time Allocation Table for Non-Medical Direct Care Staff.

For example, if the 3 physicians listed in Column 2 each work 20 hours per week for your human trafficking program, then you would indicate “60 hours” in Column 3 of the Time Allocation Table for Medical Staff.

3. Columns 4 through 19: Allocate the total hours listed for each job position (Column 3) over the 11 client services (including the “Any Other Client Services” category) and the 5 administrative and other support activities (including the “Any Other Activity” category).

Refer to the Definitions of client services and activities (page 3) for definitions of the client services and administrative/other support activities shown. When completing this section, think about your staff’s work habits over the past month and report the average hours spent providing services in an average or typical week.

For example, if the 2 social workers divide their total time equally among initial client assessment, case management/case support, and client-specific administrative activities, then you would indicate “20 hours” in Column 4, Column 12, and Column 13 of the Time Allocation Table for Non-Medical Direct Care Staff.

4. Finally, make sure that the sum of hours allocated across the service and administrative activity categories (Columns 4–19) equals the total hours per week given in Column 3.

For example, the 20 hours reported for social workers in initial client assessment (Column 4) plus the 20 hours reported in case management/case support (Column 12) plus the 20 hours reported in client-specific administrative activities (Column 13) should equal the 60 hours reported under the total hours per week in Column 3 of the Time Allocation Table for Non-Medical Direct Care Staff.

For example, the 30 hours reported for physicians in initial medical services (Column 5) plus the 30 hours reported for physicians in ongoing medical services other than pharmacological dosing (Column 6) should equal the 60 hours reported under the total hours per week in Column 3 of the Time Allocation Table for Medical Staff.

Definitions of Client Services and Activities

Client Services

Column #

Case Management:

Housing:

Service 3:

Service 4:

Service 5:

Service 6:

Service 7:

Service 8:

Service 9:

Service 10:

Service 11:

Administrative and Other Support Activities

Program Administration:

Training:

Data Collection/Case Notes:

Collaboration Development:

Administrative or Support Activity 5:

B. Weekly Service Provision

For the client services indicated below, we request information on services provided at your human trafficking program in an average week over the past month. Refer to the definitions of the client services and administrative and other support activities on page 3. When completing this section, think about the services your staff provided over the past month.

B1. How many individuals receive Case Management in an average week at your human trafficking program?

________ persons per week

B2. What is the average length of time for a Case Management session?

________ minutes per session

B3. How many individuals receive Screening and Assessment in an average week at your human trafficking program?

________ persons per week

B4. What is the average length of time for a Screening and Assessment session?

________ minutes per session

B5. How many individuals receive Client Outreach in an average week at your human trafficking program?

________ persons per week

B6. What is the average length of time for a Client Outreach session?

________ minutes per session

B7. How many individuals receive Service 4 in an average week at your human trafficking program?

________ persons per week

B8. What is the average length of time for a Service 4 session?

________ minutes per session

B9. How many individuals receive Service 5 in an average week at your human trafficking program?

________ persons per week

B10. What is the average length of time for a Service 5 session?

________ minutes per session

B11. How many individuals receive Service 6 in an average week at your human trafficking program?

________ persons per week

B12. What is the average length of time for a Service 6 session?

________ minutes per session

B13. How many individuals receive Service 7 in an average week at your human trafficking program?

________ persons per week

B14. What is the average length of time for a Service 7 session?

________ minutes per session

B15. How many individuals receive Service 8 in an average week at your human trafficking program?

________ persons per week

B16. What is the average length of time for a Service 8 session?

________ minutes per session

B17. How many individuals receive Service 9 in an average week at your human trafficking program?

________ persons per week

B18. What is the average length of time for a Service 9 session?

________ minutes per session

B19. How many individuals receive Service 10 in an average week at your human trafficking program?

________ persons per week

B20. What is the average length of time for a Service 10 session?

________ minutes per session

B21. How many individuals receive Service 11 in an average week at your human trafficking program?

________ persons per week

B22. What is the average length of time for a Service 11 session?

________ minutes per session

C. Labor Wage Rates

1. Regular Paid Employees

This section collects information on the average wages for your regular paid employees only. Wage information on contracted employees and estimated wage information on volunteer workers is collected in the Cost Module.

C1. Please enter the wage information requested in the table separately for each job position as follows:

Column B: For each job position shown, report the number of regular paid employees (do not include contracted employees and volunteer workers) that you have working at your human trafficking program.

Column C: Next, for that job position, record the average unloaded hourly wage (i.e., the wage without fringe benefits or payroll taxes included) for all regular paid employees in this job position.

When completing this section, think about the hourly wage rate earned by regular paid employees at your program during the previous month.

Important: If your data on staff wages are expressed in terms of weekly or monthly salary, please divide by the following standardized hours to obtain an hourly wage rate for each paid employee:

Weekly Salary: Divide by 40 hours (or by number of hours worked in a typical
week if employee works less than full-time).

Monthly Salary: Divide by 167 hours (or by number of hours worked in a typical
month if employee works less than full-time).

EXAMPLES

The hourly wage rate for a full-time employee with a weekly base salary of $800 would be: $800 ÷ 40 hours = $20.00 per hour.
The hourly wage rate for an employee who works only 25 hours per week with a weekly base salary of $800 would be: $800 ÷ 25 hours = $32.00 per hour.
The hourly wage rate for a full-time employee with a monthly base salary of $4,000 would be: $4,000 ÷ 167 hours = $23.95 per hour.
The hourly wage rate for an employee who works only 84 hours per month with a monthly base salary of $4,000 would be: $4,000 ÷ 84 hours = $47.62 per hour.

The first line has been completed as an example. It shows that Program Z employs 3 certified case managers. The unloaded wages for these case managers are $12, $13.75, and $9.95. In Column A, the director of Program Z chooses Case Manager (certified) and reports “3” in Column B. He reports $11.90 as the average unloaded wage in Column C (calculated as the sum of $12, $13.75, and $9.95 divided by 3).

A. Job Position	B. Number of Employees	C. Average Hourly Wage Rate (without fringes or payroll taxes) ($)
Example: Case Manager (certified)	3	$11.90

Non-Medical Direct Care Staff
Top of Form Job Type 1Bottom of Form
Job Type 2
Job Type 3
Job Type 4
Job Type 5
Job Type 6
Job Type 7
Job Type 8
Job Type 9
Job Type 10
Job Type 11
Job Type 12
Other Nonmedical Personnel
Medical Staff
Job Type 13
Job Type 14
Job Type 15
Job Type 16
Job Type 17
Job Type 18
Job Type 19
Job Type 20
Job Type 21
Other Medical Personnel

Continue with C1 on the next page 

A. Job Position	B. Number of Employees	C. Average Hourly Wage Rate (without fringes or payroll taxes) ($)
Management, Administrative, or Other Staff
Job Type 22
Job Type 23
Job Type 24
Job Type 25
Job Type 26
Job Type 27
Job Type 28
Job Type 29
Job Type 30
Other Management (e.g., vice president, CEO, finance manager)
Other Administrative (e.g., finance clerk, billing coordinator)
Other (e.g., housekeeping)

C2. Please indicate the typical percentage of base salary that was spent during the previous month on employee benefits/payroll taxes for full-time employees.

Total Fringe Benefits ________ % of base salary

AND

Total Payroll Taxes ________ % of base salary

Total Benefits/Payroll Taxes ________ % of base salary

C2a. Please indicate which of the following employee benefits/payroll taxes are included in the percentage(s) provided above.

Yes



a. Health Insurance  

b. Pension and Retirement  

c. Disability  

d. Vacation  

e. Sick Leave  

f. FICA (Federal Insurance Contributions Act)  

g. Federal and/or State Unemployment Insurance  

h. Worker’s Compensation Insurance  

i. Other  

C3. Do the fringe benefit and payroll tax rates you provided in question C2 also apply to employees who work part-time?

Yes  (Thank you for your participation)

No  (Go to C4 on next page)

C4. Please indicate the typical percentage of base salary that was spent during the previous month on employee benefits/payroll taxes for part-time employees.

Total Fringe Benefits ________ % of base salary

AND

Total Payroll Taxes ________ % of base salary

Total Benefits/Payroll Taxes ________ % of base salary

C4a. Please indicate which of the following employee benefits/payroll taxes are included in the percentage(s) provided above.

Yes



a. Health Insurance  

b. Pension and Retirement  

c. Disability  

d. Vacation  

e. Sick Leave  

f. FICA (Federal Insurance Contributions Act)  

g. Federal and/or State Unemployment Insurance  

h. Worker’s Compensation Insurance  

i. Other  

THANK YOU FOR YOUR PARTICIPATION

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Human Trafficking Evaluation Cost Module/Human Trafficking Evaluation Labor Module (A-6)

Evaluation of Domestic Human Trafficking Demonstration Projects

Eval_Trafficking_SSA_Appendix_A-6_Cost_Modules_clean_02_22_16

Human Trafficking Evaluation Cost Module/Human Trafficking Evaluation Labor Module (A-6)

OMB: 0970-0487

Appendix A-6: Cost/Labor Modules

Appendix A-6:
Cost/Labor Modules