Cost analysis - baseline

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Cooperative Re-Engagement Controlled Trial (CoRECT)

Attachment #13a

Baseline /Standard of Care Costs CLINIC

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 13a: Baseline /Standard of Care Costs CLINIC				Rev: 01/18/2015
Site name: _______________________________________				Completed Date: _________________
Data collection period (MM/DD/2016 -- MM/DD/2018)

Variable	Description	Responsible staff (ex. nurse, social worker, physician)a	Frequency Count/Week, Month b	Total Time Spent (hr)b
Generate missed visit list (per activity or event)	Time spent generating list for patients that have missed appointments		_______/_____
Records review (per patient)	Review of medical charts prior to contacting patients		______/_____
Outreach to patient (per patient)	Time spent attempting to reach patients with missed appointments (ex: phone calls, mailing letters, sending emails or texts)		______/_____
Engagement assistance (per patient)	Once contact patient, how much time is spent facilitating re-engagement (i.e.: coordinating transportation, case management, expedited appointment )		______/_____
Documentation of engagement assistance (per patient)	Time spent documenting in medical chart attempts made to contact patient and outcome		______/_____

^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.

Please check each activity that is applicable and record the time spent in minutes.

Activity	Time Spent (min)		Activity	Time Spent (min)
Generate missed visit list (per activity or event) ___ Time spent generating list for patients that have missed appointments	_____/min		Records review (per patient) ___ Review of medical charts prior to contacting patients	_____/min
Outreach to patient (attempting to reach patients with missed appointments, per patient) ___phone calls ___mailing letters ___sending emails or texts ___others:	_____/min		Engagement assistance (once contact patient, how much time is spent facilitating re-engagement, per patient) ___coordinating transportation ___case management ___expedited appointment ___Others:	_____/min
Time spent documenting in medical chart attempts made to contact patient and outcome (per patient)	_____/min