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pdfDepartment of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved
OMB NO 0938-0599
Clinical Laboratory Improvement Amendments Program
Budget/Expenditure Report
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Jeffrey Pleines.
Agency:
Region/State Code:
Budget Period: FY 2004
FY Quarter:
Colorado Department of Public Health & Environment
8 / Colorado
From: 10/1/2003 To: 12/31/2003
1/2004
(1) CLIA State Budget Request
(5) CLIA Cumulative Quarterly Expenditures
(2) CLIA RO Budget Approval
(6) CLIA Supplemental
(3) CLIA State Quarterly Expenditures
(7) Other (Explain)
(4) CLIA RO Approved Quarterly Expenditures
CLIA
Cost Centers
Staff
Years
Amount
Cumulative
Expenditures
(A)
(B)
(C)
Salaries
1A
Surveyor/Professional
0.00
0.00
0.00
1B
Non-Surveyor/Professional
0.00
0.00
0.00
1C
Supervisor
0.00
0.00
0.00
2
Clerical
0.00
0.00
0.00
3
Total Salaries
0.00
0.00
0.00
Other Direct Cost
4
Rate %
5
Ret/Fringe Benefits
0.00
0.00
6
Travel
0.00
0.00
7
Communications
0.00
0.00
8
Supplies
0.00
0.00
9
Office Space
0.00
0.00
10
Equipment Purchases
0.00
0.00
11
Training
0.00
0.00
12
Consultants
0.00
0.00
13
Subcontracts
0.00
0.00
14
Miscellaneous
0.00%
0.00
0.00
14A
0.00
0.00
14B
0.00
0.00
14C
0.00
0.00
14D
0.00
0.00
14E
0.00
0.00
14F
0.00
0.00
14G
0.00
0.00
15
Total Other Direct Costs
0.00
0.00
16
Total Direct Costs
0.00
0.00
17
Rate % 0
18
Indirect Costs
0.00
0.00
19
Total Costs
0.00
0.00
20
Unliquidated Obligation
0.00
0.00
0.00%
Hourly Rate
Total Cost
Total Staff Years
0.00
Date:
Form CMS -102
Signature:
Hrs. Per Staff Yrs.
0.00
Hourly Rate
1.00
0.00
Title:
Date Revised: 03/24/2004
Wednesday, March 24, 2004 - 03:43 PM
| File Type | application/pdf |
| File Title | CMS-102 |
| Author | Jeffrey Pleines |
| File Modified | 2017-11-13 |
| File Created | 2017-11-13 |