Business Proposal Forms

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QUALITY IMPROVEMENT ORGANIZATION __th SOW BUSINESS PROPOSAL SUMMARY
CENTERS FOR MEDICARE and MEDICAID SERVICES

1. Name and Address of QIO Organization

3. RFP #

4: Proposed Contract Period
2. QIO Area (State):

From:
To:

Medicare
Contract

5. Total Proposed
Costs

6. CMS Recommended
Costs

7. $
Difference

8. %
DIfference

Direct Cost
a. LABOR:
1. Professional
2. Information Systems
3. Corporate Management
4. Support Staff

$0
$0
$0
$0

$0
$0
$0
$0

$0
$0
$0
$0

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

$0

$0

$0

#DIV/0!

$0
$0

$0
$0

$0
$0

#DIV/0!
#DIV/0!

$0

$0

$0

#DIV/0!

1. Physician Reviewers/ Phys.Advisors
2. Other Consultants
3. Other Subcontracts

$0
$0
$0

$0
$0
$0

$0
$0
$0

#DIV/0!
#DIV/0!
#DIV/0!

SUBTOTAL - Subcontractors

$0

$0

$0

#DIV/0!

$0
$0

$0
$0

$0
$0

#DIV/0!
#DIV/0!

$0

$0

$0

#DIV/0!

g. Indirect Costs
h. Pass-thru Costs

$0
$0

$0
$0

$0
$0

#DIV/0!
#DIV/0!

TOTAL COSTS

$0

$0

$0

#DIV/0!

$0

$0

$0

#DIV/0!

$0

$0

$0

#DIV/0!

SUBTOTAL - Direct Labor
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave/Fringe
d. Subcontractors

e. Travel
f. Other Direct Costs

SUBTOTAL - DIRECT

i. Fee
TOTAL COST WITH FEE
9.

10. Signature of Authorized Official:

CMS USE ONLY

Fringe Rate
14. Proposal Receipt Date:
Indirect Rate

11. Type or Print Name and Title:

Other Rate

15. Reviewed By:

Indirect Leave Rate
12. DATE:

13. Telephone #
16. Signature/Title:

Quality Improvement Organization __th SOW Business Proposal
Centers for Medicare and Medicaid Services

1. RFP Number:
0

2. Name and Address of QIO Organization:
0
0
0

3. QIO Area (State):

4. Contract Period
From:
12/30/1899
To:
12/30/1899

0

MEDICARE COSTS
HOURS

COSTS

HOURS

COSTS

HOURS

COSTS

HOURS

COSTS

HOURS

COSTS

a. LABOR:
1. Professional

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

2. Information Systems

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

3. Corporate Management

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

4. Support Staff

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

SUBTOTAL - Direct Labor

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe

$0
0.0

$0

0.0

$0

$0
0.0

$0

$0
0.0

$0

$0
0.0

$0

$0
0.0

$0

d. Subcontracts:
1. Physician Reviewers / Phys. Advisors
2. Other Consultants

$0

$0

$0

$0

3. Other Subcontractors

$0

$0

$0

$0

SUBTOTAL - Subcontracts

0.0

$0

0.0

$0

0.0

$0

0.0

$0

e. Travel

$0

$0

$0

$0

f. Other Direct Costs
SUBTOTAL - DIRECT

$0
$0

$0
$0

$0
$0

$0
$0

0.0

0.0

0.0

0.0

$0
$0
0.0

$0
$0

0.0

$0
$0

g. Indirect Costs

$0

$0

$0

$0

$0

h. Pass-thru Costs

$0

$0

$0

$0

$0

TOTAL COSTS
i. Fee
TOTAL COSTS WITH FEE

Form 719 BP

0.0

$0
$0
$0

0.0

$0
$0
$0

0.0

$0
$0
$0

Page 2

0.0

$0
$0
$0

0.0

$0
$0
$0

Prepared on:

Quality Improvement Organization __th SOW Business Proposal
Centers for Medicare and Medicaid Services

1. RFP Number:
0

MEDICARE COSTS
HOURS

COSTS

HOURS

COSTS

HOURS

COSTS

HOURS

COSTS

a. LABOR:
1. Professional

0.0

$0

0.0

$0

0.0

$0

0.0

$0

2. Information Systems

0.0

$0

0.0

$0

0.0

$0

0.0

$0

3. Corporate Management

0.0

$0

0.0

$0

0.0

$0

0.0

$0

4. Support Staff

0.0

$0

0.0

$0

0.0

$0

0.0

$0

SUBTOTAL - Direct Labor

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe

$0
0.0

$0

$0
0.0

$0

$0
0.0

$0

$0
0.0

$0

d. Subcontracts:
1. Physician Reviewers / Phys. Advisors
2. Other Consultants

$0

$0

$0

3. Other Subcontractors

$0

$0

$0

SUBTOTAL - Subcontracts

0.0

$0

0.0

$0

0.0

$0

e. Travel

$0

$0

$0

f. Other Direct Costs
SUBTOTAL - DIRECT

$0
$0

$0
$0

$0
$0

0.0

0.0

0.0

$0
$0
0.0

$0
$0

0.0

$0
$0

g. Indirect Costs

$0

$0

$0

$0

h. Pass-thru Costs

$0

$0

$0

$0

TOTAL COSTS
i. Fee
TOTAL COSTS WITH FEE

Form 719 BP

0.0

$0
$0
$0

0.0

$0
$0
$0

0.0

$0
$0
$0

Page 3

0.0

$0
$0
$0

Prepared on:

Quality Improvement Organization __th SOW Business Proposal
Centers for Medicare and Medicaid Services

1. RFP Number:
0

TOTAL

MEDICARE COSTS
HOURS

COSTS

HOURS

COSTS

HOURS

COSTS

HOURS

COSTS

a. LABOR:
1. Professional

0.0

$0

0.0

$0

0.0

$0

0.0 $

-

2. Information Systems

0.0

$0

0.0

$0

0.0

$0

0.0 $

-

3. Corporate Management

0.0

$0

0.0

$0

0.0

$0

0.0 $

-

4. Support Staff

0.0

$0

0.0

$0

0.0

$0

0.0 $

-

SUBTOTAL - Direct Labor

0.0

$0

0.0

$0

0.0

$0

0.0 $

-

0.0

$0

0.0

$0

0.0

$0

0.0 $

-

$0

$

-

$0

0.0 $

-

b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe

$0
0.0

$0

$0
0.0

$0

0.0

d. Subcontracts:
1. Physician Reviewers / Phys. Advisors

0.0 $

-

2. Other Consultants

$0

$0

$0

$

-

3. Other Subcontractors

$0

$0

$0

$

-

$0

0.0 $

-

SUBTOTAL - Subcontracts

0.0

$0

0.0

$0

0.0

e. Travel

$0

$0

$0

$

-

f. Other Direct Costs
SUBTOTAL - DIRECT

$0
$0

$0
$0

$0
$0

$

$0

0.0

0.0

0.0

0.0

g. Indirect Costs

$0

$0

$0

$

-

h. Pass-thru Costs

$0

$0

$0

$

-

$

$0
-

$

-

TOTAL COSTS
i. Fee
TOTAL COSTS WITH FEE

Form 719 BP

0.0

$0
$0
$0

0.0

$0
$0
$0

0.0

$0
$0
$0

Page 4

0.0

Prepared on:

FRINGE BENEFIT PROPOSAL
QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICES

1. Name and Address of QIO Organization
0
0
0

3. RFP #

2. QIO Area (State):

From:

12/30/1899

To:

12/30/1899

0
4: Proposed Contract Period

0

DETAIL COSTS

6. Prior Year
Total
Organization Costs

7. Projected
Total 5-YR
Organization Costs

8. Prior Year
Total
Medicare Costs

9. Projected
Total 5-YR
Medicare Costs

Fringe Benefits
a. Employer's FICA Expense
b. Federal Unemployment Insurance
c. State Unemployment Insurance
d. Disability Insurance
e. Pension Expense
f. Workers Compensation
g. Group Health Insurance
h. Group Life Insurance
i. Empl. Relations & Welfare
j. Leave
k. Other - see attached
l. Total Fringe Benefits
m. Fringe Benefit Rate

Form 720 BP

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.00%

$0
0.00%

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.00%

$0
0.00%

09/16/2026

INDIRECT AND OTHER DIRECT COST
QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICES
1. Name and Address of QIO Organization
0
0
0

3. RFP #

2. QIO Area (State):

From:

12/30/1899

To:

12/30/1899

0
4: Proposed Contract Period

0

DETAIL COSTS

5. Prior Year
6. Projected
7. Prior Year
8. Projected
Total
Total 5yr.
Medicare
Medicare 5yr
Indirect Costs Indirect Costs Indirect Costs Indirect Costs

a. Indirect Labor
b. Indirect Leave
c. Indirect Fringe
d. Rent
e. Storage
f. Utilities
g. Maintenance & Repairs
h. Depreciation
i. Data Processing
j. Equipment Leasing & Rental
k. Office Supplies
l. Reproduction & Printing
m. Telephone
n. Postage & Express Mail
o. Consultants
p. Meeting & Conferences
q. Travel
r. Training
s. Garage & Parking Spaces
t. Dues & Subscriptions
u. Recruiting
v. Temporary Help
w. Continuing Education
x. Legal Fees
y. Accounting/Audit Fees
z. Board of Directors Fees
aa. Insurance
bb. Bank Charges
cc. Other - see attached

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

dd. ** TOTAL

$0

$0

ee. Indirect Cost Rate

Form 721 BP

0.00%

9. Prior Year
Medicare
Other Direct.

10. Projected
Medicare 5yr
Other Direct.

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0

$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0

$0

0.00%

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

5. Proposed

1. Staff
Name

2. Position
Title

3. Labor
Category Code

4. Current
Hourly Rate

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Form Staffing

Page 7

Year 1
6. Percent
Hourly Rate
Change
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7. Proposed

Year 2
Hourly Rate

9. Proposed

8. Percent
Change
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Year 3
Hourly Rate

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

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51
52
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60
61
62
63
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65
66
67
68
69
70
71
72

Form Staffing

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Page 8

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09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

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87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
Grand Total
By Category
P=Professional
I=Info Systems
C=Corp Mgmt

Form Staffing

N/A

N/A

N/A

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Page 9

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09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

S=Support Staff
Check Cell for Columns: Sum of 114 through 117 should equal value in 112

Form Staffing

#DIV/0!

Page 10

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09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

17. Average
11. Proposed

1. Staff
Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Form Staffing

10. Percent
Change
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Year 4
Hourly Rate

13. Proposed

12. Percent
Change
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Year 5
Hourly Rate

Page 11

15. Average

14. Percent
Change
Hours Per Year
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16. Total 5yr

Labor Costs

Hours Per Year
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

32
33
34
35
36
37
38
39
40
41
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43
44
45
46
47
48
49
50
51
52
53
54
55
56
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58
59
60
61
62
63
64
65
66
67
68
69
70
71
72

Form Staffing

#DIV/0!
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#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

Page 12

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
Grand Total
By Category
P=Professional
I=Info Systems
C=Corp Mgmt

Form Staffing

N/A

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!

#DIV/0!
#DIV/0!
#DIV/0!

Page 13

0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0

0.0 $
0.0 $
0.0 $

-

0.0
0.0
0.0

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

S=Support Staff
#DIV/0!
#DIV/0!
Check Cell for Columns: Sum of 114 through 117 should equal value in 112

Form Staffing

#DIV/0!

#DIV/0!

Page 14

#DIV/0!

0.0 $
0.0 $

-

0.0
0.0

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

18. Total 5yr

1. Staff
Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Form Staffing

Labor Costs
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

19. Average

20. Total 5yr

Hours Per Year

Labor Costs
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

Page 15

21. Average

22. Total 5yr

23. Average

Hours Per Year

Labor Costs Hours Per Year
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

24. Total 5yr

Labor Costs
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72

Form Staffing

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

Page 16

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
Grand Total
By Category
P=Professional
I=Info Systems
C=Corp Mgmt

Form Staffing

N/A

$
$
$

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
-

0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0 $
0.0 $
0.0 $

-

Page 17

0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0 $
0.0 $
0.0 $

-

0.0 $
0.0 $
0.0 $

-

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

S=Support Staff
$
0.0 $
Check Cell for Columns: Sum of 114 through
$
117 should
- equal value in 112 0.0 $

Form Staffing

-

Page 18

0.0 $
0.0 $

-

0.0 $
0.0 $

-

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

1. Staff
Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Form Staffing

25. Average

26. Total 5yr

Hours Per Year

Labor Costs
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

27. Average

28. Total 5yr 29. Average

30. Total 5yr

Hours Per Year

Labor Costs Hours Per Year
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

Labor Costs Hours Per Year
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

Page 19

31. Average

32. Total 5yr

Labor Costs
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72

Form Staffing

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

Page 20

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
Grand Total
By Category
P=Professional
I=Info Systems
C=Corp Mgmt

Form Staffing

N/A

0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0 $
0.0 $
0.0 $

-

0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0 $
0.0 $
0.0 $

-

Page 21

0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0 $
0.0 $
0.0 $

-

0.0 $
0.0 $
0.0 $

-

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

S=Support Staff
0.0 $
Check Cell for Columns: Sum of 114 through 117 should
0.0equal
$
value in 112
-

Form Staffing

0.0 $
0.0 $

Page 22

-

0.0 $
0.0 $

-

0.0 $
0.0 $

-

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

1. Staff
Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Form Staffing

33. Average

34. Total 5yr

35. Average

36. Total 5yr.

Hours Per Year

Labor Costs Hours Per Year
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

37. Average

Labor Costs Hours Per Year
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

Page 23

38. Total 5yr

39. Average

40. Total 5yr

Total Direct Labor Direct
Labor Costs Hours Per Year
Labor Costs
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72

Form Staffing

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

Page 24

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
Grand Total
By Category
P=Professional
I=Info Systems
C=Corp Mgmt

Form Staffing

N/A

0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0 $
0.0 $
0.0 $

-

0.0 $
0.0 $
0.0 $

-

Page 25

0.0
0 $
0 $
0 $

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

-

0.0 $
0.0 $
0.0 $

-

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

S=Support Staff
0.0 $
Check Cell for Columns: Sum of 114 through 117 should
0.0equal
$ value in 112
-

0.0 $
0.0 $

Form Staffing

Page 26

-

0 $
0 $

-

0.0 $
0.0 $

-

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

41. Average

1. Staff
Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Form Staffing

INDIRECT
Prof.
42. Total
Hours5yr 43. Average

44. Total

45. Average

46. Total 5yr

Indirect Labor
per
Indirect
year
Total Labor
5yr
Direct Leave
Direct Leave
Hours Per Year avg
Labor Costs Hours Per Year Labor Costs
Hours Per Year Costs
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0
###
$0
0.0
$0

N
O
T

Page 27

A
P
P

###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0

DIRECT LEAVE
Prof.
47. Average
Labor

48. Total 5yr

costs/yr
Leave
avg
Hours Per Year

Leave
Costs
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

09/16/2026

A
P
P
L
I
C
A
B
L
E

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72

Form Staffing

###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0

Page 28

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

09/16/2026

L
E

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
Grand Total
By Category
P=Professional
I=Info Systems
C=Corp Mgmt

Form Staffing

N/A

###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0 $
0.0 $
0.0 $

-

0.0 $
0.0 $
0.0 $

-

Page 29

0.0

###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0
###
$0

0.0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.0 $
0.0 $
0.0 $

-

0.0 $
0.0 $
0.0 $

-

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

S=Support Staff
0.0 $
Check Cell for Columns: Sum of 114 through 117 should
0.0 equal
$
value in- 112

Form Staffing

0.0 $
0.0 $

Page 30

-

0.0 $
0.0 $

-

0.0 $
0.0 $

-

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

49. Average T50. Leave as a

1. Staff
Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Form Staffing

51. Total 5yr

Leave Hours % of Hours
Leave
Per Year
Worked
Costs
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!

52. Average Total

53. Total 5yr

Labor and Leave
Hours Per Year

Labor/
Leave Costs

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Page 31

55. FTEs PER YEAR BY CATEGORY
56.A

54. FTE
Per Year
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00
$0
0.00

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72

Form Staffing

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Page 32

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
Grand Total
By Category
P=Professional
I=Info Systems
C=Corp Mgmt

Form Staffing

N/A

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0

#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.0
0.0
0.0

#DIV/0! $
#DIV/0! $
#DIV/0! $

-

0 $
0 $
0 $

-

0
0
0

Page 33

09/16/2026

Staffing Proposal
Personnel Loading Chart
Quality Improvement Organization __th SOW Business Proposal

S=Support Staff
0.0
#DIV/0! $
Check Cell for Columns: Sum of 114 through 117 should
0.0
equal value
#DIV/0!
in 112
$

Form Staffing

-

0 $
0 $

Page 34

-

0
0.00

09/16/2026

Subcontracts Proposal Quality Improvement Organization __th SOW Business Proposal
Physician Reviewers and Physician Advisors

Physician Reviewer Cost for Beneficiary & Family Centered Care Activities
1. Current
2
3
4
5
Phys. Reviewer
Number of
Hours
Hours
Phys. Reviewer
Hourly Rate
Reviews
Per Review
Per Year
Hourly Rate

6.
Benef. and FCC
Review Costs

0.0

7

8
Number of
Reviews

9
Hours
Per Review

10
Phys. Reviewer
Hourly Rate

Hours
Per Year

$0

11.
Benef. and FCC
Review Costs

0.0

12

13
Number of
Reviews

14
Hours
Per Review

$0

15
Phys. Reviewer
Hourly Rate

Hours
Per Year

16
Benef. and FCC
Review Costs

0.0

17

18
Number of
Reviews

19
Hours
Per Review

$0

20
Phys. Reviewer
Hourly Rate

Hours
Per Year

21
Benef. and FCC
Review Costs

0.0

22

23
Number of
Reviews

24
Hours
Per Review

25
Phys. Reviewer
Hourly Rate

Hours
Per Year

0.0

Form SC 1

$0

26

27. Total
Benef. and FCC
Review Costs

Benef. and FCC
Review Costs

$0

$0

Prepared on:

Form SC 2

Subcontracts Proposal
Quality Improvement
Organization __th SOW Business Proposal
Other Consultants and Other Subcontractors
A

B

1
2
3

F

G

2. Total 5 Years

3. Total 5 Years

4. Total 5 Years

5. Total 5 Years

6. Total 5 Years

1 Other Consultants:
a

8
9
10
11
12
13
14
15
16
17

b
c
d
e
f
g
h
i
j
k (See Attached)

Subtotal - Other Consultants

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

2 Other Subcontractors:

21

a

22
23
24
25
26
27
28
29
30
31

b

32

E

Name

7

18
19
20

D

1.

4
5
6

C

c
d
e
f
g
h
i
j
k (See Attached)

Subtotal - Other Subcontractors

Page 36

Prepared on:

Subcontracts Proposal
Quality Improvement
Organization __th SOW Business Proposal
Other Consultants and Other Subcontractors
A

B

1
2
3

a
b

L

M

S

7. Total 5 Years

8. Total 5 Years

9. Total 5 Years

10. Total 5 Years

11. Total 5 Years

12. Total 5 Years

13. Total 5 Years

c
d
e
f
g
h
i
j
k (See Attached)

Subtotal - Other Consultants

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

2 Other Subcontractors:

21

a

22
23
24
25
26
27
28
29
30
31

b

Form SC 2

K

1 Other Consultants:

8
9
10
11
12
13
14
15
16
17

32

J

Name

7

18
19
20

I

1.

4
5
6

H

c
d
e
f
g
h
i
j
k (See Attached)

Subtotal - Other Subcontractors

Page 37

Prepared on:

Form SC 2

Subcontracts Proposal
Quality Improvement
Organization __th SOW Business Proposal
Other Consultants and Other Subcontractors
A

B

1
2
3

14.

1.

4
5
6

5 YR Costs

1 Other Consultants:
a

8
9
10
11
12
13
14
15
16
17

b

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

c
d
e
f
g
h
i
j
k (See Attached)

Subtotal - Other Consultants

$0

2 Other Subcontractors:

21

a

22
23
24
25
26
27
28
29
30
31

b

32

Total

Name

7

18
19
20

T

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

c
d
e
f
g
h
i
j
k (See Attached)

Subtotal - Other Subcontractors

Page 38

$0

Prepared on:

Form SC 2

Subcontracts Proposal
Quality Improvement
Organization __th SOW Business Proposal
Other Consultants and Other Subcontractors
A

B

1
2
3

1.

4
5
6

16.
Current Activity

Proposed Activity

1 Other Consultants:
a

8
9
10
11
12
13
14
15
16
17

b
c
d
e
f
g
h
i
j
k (See Attached)

Subtotal - Other Consultants
2 Other Subcontractors:

21

a

22
23
24
25
26
27
28
29
30
31

b

32

V

15
Name

7

18
19
20

U

c
d
e
f
g
h
i
j
k (See Attached)

Subtotal - Other Subcontractors

Page 39

Prepared on:

Staffing Proposal Summary
Quality Improvement
Organization __th SOW Business Proposal

Labor Category
Professional
Information Systems
Corporate Management
Support Staff
Total

Form Sum

1. Average
2. Proposed
4. Proposed
6. Proposed
8. Proposed
Current
Average Year 1
3. Percent
Average Year 2 5. Percent
Average Year 3 7. Percent Average Year 4 9. Percent
Hourly Rate
Hourly Rate
Change
Hourly Rate
Change
Hourly Rate
Change Hourly Rate
Change
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

Page 40

Prepared on:

Staffing Proposal Summary
Quality Improvement
Organization __th SOW Business Proposal

Labor Category
Professional
Information Systems
Corporate Management
Support Staff
Total

Form Sum

10. Proposed
12. Total
Average Year 5 11. Percent
Hourly Rate
Change
Hours
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

13. Total

14. Total

Labor Costs
0.0
0.0
0.0
0.0
0.0

15. Total

Hours
$0
$0
$0
$0
$0

Page 41

0.0
0.0
0.0
0.0
0.0

Labor Costs
$0
$0
$0
$0
$0

16. Total

17. Total

Hours

18. Total

Labor Costs
0.0
0.0
0.0
0.0
0.0

Hours
$0
$0
$0
$0
$0

0.0
0.0
0.0
0.0
0.0

Prepared on:

Staffing Proposal Summary
Quality Improvement
Organization __th SOW Business Proposal

19. Total
Labor Category
Professional
Information Systems
Corporate Management
Support Staff
Total

Form Sum

Labor Costs
$0
$0
$0
$0
$0

20. Total

21. Total

Hours

22. Total 23. Total

Labor Costs
0.0
0.0
0.0
0.0
0.0

Hours
$0
$0
$0
$0
$0

24. Total

Labor Costs
0.0
0.0
0.0
0.0
0.0

Page 42

25. Total

Hours
$0
$0
$0
$0
$0

26. Total

Labor Costs
0.0
0.0
0.0
0.0
0.0

Hours
$0
$0
$0
$0
$0

0.0
0.0
0.0
0.0
0.0

Prepared on:

Staffing Proposal Summary
Quality Improvement
Organization __th SOW Business Proposal

27. Total
Labor Category
Professional
Information Systems
Corporate Management
Support Staff
Total

Form Sum

28. Total

Labor Costs

29. Total

Hours
$0
$0
$0
$0
$0

30. Total

Labor Costs
0.0
0.0
0.0
0.0
0.0

31. Total

Hours
$0
$0
$0
$0
$0

0.0
0.0
0.0
0.0
0.0

Page 43

Labor Costs
$0
$0
$0
$0
$0

32. Total

33. Total

Hours
0.0
0.0
0.0
0.0
0.0

Labor Costs
$0
$0
$0
$0
$0

34. Total
Hours
0.0
0.0
0.0
0.0
0.0

Prepared on:

Staffing Proposal Summary
Quality Improvement
Organization __th SOW Business Proposal

Labor Category
Professional
Information Systems
Corporate Management
Support Staff
Total

Form Sum

35. Total
Labor Costs
$0
$0
$0
$0
$0

36. Total
Direct Labor
Hours
0.0
0.0
0.0
0.0
0.0

37. Total
38. Total
39. Total
Direct Labor
Indirect Labor Indirect Labor
Costs
Hours
Costs
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0
$0
0.0
$0

Page 44

40. Total
Labor
Hours
0.0
0.0
0.0
0.0
0.0

41. Total
Labor
Costs
$0
$0
$0
$0
$0

42. Total
43. Total
Direct Leave
Direct Leave
Hours
Costs
0.0
$0
0.0
$0
NOT 0.0
$0
APPLICABLE
0.0
$0
0.0
$0

Prepared on:

Staffing Proposal Summary
Quality Improvement
Organization __th SOW Business Proposal

Labor Category
Professional
Information Systems
Corporate Management
Support Staff
Total

Form Sum

44. Total
Leave
Hours

45. Total
Leave
Costs
0.0
0.0
0.0
0.0
0.0

$0
$0
$0
$0
$0

46. Total 47. Leave as a
Leave
% of Hours
Hours
Worked
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!
0.0
#DIV/0!

48. Total
49. Total
50.. Total
Leave
Labor and Leave Labor and Leave 51. Total FTE
Costs
Hours
Costs
Per Year
$0
0.0
$0
0.00
$0
0.0
$0
0.00
$0
0.0
$0
0.00
$0
0.0
$0
0.00
$0
0.0
$0
0.00

Page 45

Prepared on:

OTHER DIRECT COST
QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICES
1. Name and Address of QIO Organization
0
0
0

3. RFP #

2. QIO Area (State):

From:

12/30/1899

To:

12/30/1899

0
4: Proposed Contract Period

0

DETAIL COSTS
d. Rent
e. Storage
f. Utilities
g. Maintenance & Repairs
h. Depreciation
i. Data Processing
j. Equipment Leasing & Rental
k. Office Supplies
l. Reproduction & Printing
m. Telephone
n. Postage & Express Mail
o. Consultants
p. Meeting & Conferences
q. Travel
r. Training
s. Garage & Parking Spaces
t. Dues & Subscriptions
u. Recruiting
v. Temporary Help
w. Continuing Education
x. Legal Fees
y. Accounting/Audit Fees
z. Board of Directors Fees
aa. Insurance
bb. Bank Charges
cc. Other - see attached
TOTAL

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

Total Projected
Medicare - 5yr Other
Direct Costs
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0

$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

$0

$0

2. QIO Area (State):

1. Name and Address of QIO Organization:
0
0
0

0

4. Quality of Care Reviews
Cost Per Case
HOURS

3. Contract Period
From: 12/30/1899
To:
12/30/1899

COSTS

6. Fee-for-Service (FFS) 7. Medicare Advantage (MA)
Expedited Appeals Cost Fast Track Appeals Cost Per 8. EMTALA: 5-day Reviews
Per Case
Case
Cost Per Review

5. Hospital Based Notice
Appeals Cost Per Case
HOURS

COSTS

HOURS

COSTS

HOURS

COSTS

HOURS

COSTS

a. LABOR:
1. Professional
2. Information Systems
3. Corporate Management
4. Support Staff
SUBTOTAL - Direct Labor

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors
2. Other Consultants
3. Other Subcontractors
SUBTOTAL - Subcontracts
e. Travel
f. Other Direct Costs
SUBTOTAL - DIRECT
g. Indirect Costs

$0

$0

$0

$0

$0

h. Pass-thru Costs

$0

$0

$0

$0

$0

TOTAL COSTS
i. Fee
TOTAL COSTS WITH FEE
Projected Volume - # of cases for:
Year 1
Year 2
Year 3
Year 4

0.0

$0
$0
$0

0.0

$0
$0
$0

0.0

$0
$0
$0

0.0

$0
$0
$0

0.0

$0
$0
$0

Year 5

GRAND TOTAL:

$0

$0

$0

$0

** Please note, the totals for these activities DO NOT roll into the column BENEFICIARY & FAMILY CENTERED CARE on the form "QIO F719".

$0

9. EMTALA: 60-day Reviews
Cost Per Review
HOURS

COSTS

10. Higher Weighted DRG
Cost Per Case
HOURS

COSTS

11. Quality Improvement
Interventions (QII)/ Technical
Assistance Costs
HOURS

COSTS

12. Sanction Activities
HOURS

13. Collaboration

COSTS

HOURS

COSTS

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

0.0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0
$0
$0

0.0

$0
$0
$0

0.0

$0
$0
$0

0.0

$0
$0
$0

0.0

$0
$0
$0

$0

$0

$0

$0

$0

14. Transparency Through
Reporting
HOURS

COSTS

0.0

0.0

0.0

0.0

0.0

15. Other Non-Review
Activities
HOURS

$0

$0

$0

$0

16. Total

COSTS

0.0

0.0

0.0

0.0

HOURS

$0

$0

$0

$0

COSTS

0.0 $

-

0.0 $

-

0.0 $

-

0.0 $

-

0.0 $

-

0.0 $

-

$

-

0.0 $

-

0.0 $

-

$

-

$

-

0.0 $

-

$

-

$

$0

0.0

$0

$0

$

-

$0

$0

$

-

$

$0
-

$

-

$0
$0
$0

0.0

$0
$0
$0

0.0

$0

$0

$0

TRAVEL DETAIL
QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICES

6. Area

1. RFP Number:

2. Name and Address of QIO Organization:

0

0
0
0

7. Trip Title &
Description/Purpose

3. QIO Area (State):
0

10. # of
8. # of Days per 9. # of Nights per Travelers per 11. Airfare per 12. Departing
Trip
Trip
Trip
Person
from:

** Please note, the totals for these activities DO NOT roll into the TRAVEL line item listed on the forms entitled, "QIO F719", "QIO ODC"

OSAL
S

3. QIO Area (State):

4. Contract Period
From:
To:

12/30/1899
12/30/1899

0

5. Mileage
Rate:

14. FTR
Meals &
13. Arriving Inc. Daily
to:
Rate

15. FTR
17. Total #
Lodging per 16.
# of miles per
Night
of Trips
trip

18. # of
Rental Cars
Per Trip

19. Daily
Rental Car
Rate

20. Misc. Cost
per Person per
Trip (includes
parking, gas,
taxi, etc.)

21. TOTAL

22. Notes
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

s entitled, "QIO F719", "QIO ODC", or "BFCC Sup Sch".

$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0

23. GRAND TOTAL:

$0

22. Notes