Annual Cost Analysis - health dept

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Cooperative Re-Engagement Controlled Trial (CoRECT)

Attachment #13d

Annual Implementation Costs for CoRECT- Health Department

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 13d Annual Implementation 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. Out-of-care list generation

2. DIS activities

3. Administration time

4. Office supplies

5. Durable material

6. Facility space and utilities

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

(2) DIS activities	Description	Responsible staff (ex. study coordinator, DIS, data manager) ac	Frequency Count/Week, Month bc	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	__________________	_______/_____ _______/_____ _______/_____
Other		__________________	_______/_____ _______/_____ _______/_____

^{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) Administration Time	Responsible staff (ex. clinic nurse, physicians, data manager) a	Frequency Count/Week, Month b	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) 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)______________	________	$________	$________

(5) Durable material/equipment cost
Data from this section will be used to estimate the annual cost of durable items. 'Unit cost' may be based on the estimated remaining value of the item purchased previously, or the new purchase price.
Description	Unit/quantity	Unit costs ($)	Remaining useful life (year)	% used for this project	Annual total costs
Desktop computer a	________	$________
Laptop computer	________	$________
Furniture b	________	$________
Other (e.g., cell phone, pager)	________	$________
specify: ______________________	________	$________
specify: ______________________		$________
aOnly report cost of CoRECT computers used by DIS/field epi bReport only if new furniture purchased for this project

(6) Facility space and utilities	Monthly total costs
Office space for DIS/Field epi
Other
Utilities:
Telephone (local, long distance)
Internet
Other (specify):______________
Other (specify):______________

(7) Health Department Staff Salaries	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 ______________________)	$__________	__________ %	__________ %
Others (specify _______________________)	$__________	__________ %	__________ %

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