| Form Approved OMB NO: 0920-xxxx Exp. Date: X/XX/XXXX |
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| Public reporting burden of this collection of information is estimated at 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/Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-xxxx). | ||||
| Program Details | Comments | Highlighting Key | ||
| 1A. Program Name | Purple = Enter program information | |||
| Yellow = Automatically populated and/or to be entered by CDC | ||||
| 1B. Program Director | Blue - Enter any comments, feedback, or questions | |||
| Name | ||||
| Telephone | ||||
| 1C. Primary financial/administrative contact person | ||||
| Name | ||||
| Telephone | ||||
| Worksheet for Recording the Total Funds Allocated to Your Program Per Award Year ( All Funds Including CDC Core SIPP Award and Other Federal or Non-Federal Funds Allocated to Core SIPP Strategies and Topics) | |||||
| Year 1 (08/01/2021 - 07/31/2022) | |||||
| 2A. CDC Core SIPP Funding | $ Amount | Comments | |||
| Total CDC Core SIPP funding for current year* | |||||
| Unobligated funds carried forward from previous year | N/A | ||||
| Amount of fund unspent for the current year | |||||
| Total CDC Core SIPP funding allocated: | $0.00 | ||||
| * Core SIPP funds are defined as those funds that were awarded directly by CDC through the CDC-RFA-CE21-2101 program announcement. | |||||
| Year 1 (08/01/2021 - 07/31/2022) | Comments | ||||
| 2B. Source of other funding (other federal or non-federal) allocated to Core SIPP Strategies and Topics | $ Amount | Strategy | Topic | ||
| (e.g.) Non-CDC Federal Funds | $100,000.00 | Data and Surveillance | Child Abuse and Neglect | ||
| (e.g.) Private Grants | $5,000.00 | Assessment and Evaluation | All Topics | ||
| Total other funds: | $0.00 | ||||
| Total funds allocated: $ | $0.00 | ||||
| Note: While cost sharing or matching funds were not required for this program, leveraging other resources and related ongoing efforts to promote sustainability was strongly encouraged in the NOFO. | |||||
| Worksheet for Estimating the Value of In-Kind Contributions Per Award Year | |||||||||
| Year 1 (08/01/2021 - 07/31/2022) | |||||||||
| 3A. Labor In-Kind Contributions | Hours Contributed | $ Value | Strategy | Topic | Method Used to Estimate $ Value | Comments | |||
| (e.g.) Student intern | 240 | Data and Surveillance | ACEs | ||||||
| Total: | $0.00 | ||||||||
| 3B. Non-Labor In-Kind Contributions | # of Units | $ Value per unit | Total Cost | Strategy | Topic | Method Used to Estimate $ Value | Prorated Value | Comments | |
| (e.g.) Donated space for campaign kick-off event | 1 | $300 | $300 | Data and Surveillance | Intimate Partner/Sexual Violence | ||||
| (e.g.) Dell Laptops | 5 | $500 | $2,500 | All Strategies | All Topics | ||||
| $0.00 | |||||||||
| $0.00 | |||||||||
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| Total: | $0.00 | $0.00 | |||||||
| Total Year 1: | $0.00 | ||||||||
| Worksheet for Estimating Personnel Costs Per Award Year | ||||||||||
| Year 1 (08/01/2021 - 07/31/2022) | FTE % (a full- time employee is 100%) | % Time Spent on Core SIPP Strategies | % Time Spent on CORE SIPP Topics | Salary (salaries are the total annual salaries earned by staff and not only amounts related to Core SIPP activities) | % Salary Paid by Sources | Comments | ||||
| Personnel | Base | Fringe | Total | % Salary paid by CDC Core SIPP funding | % Salary paid by other source | |||||
| (e.g) | Project Director | 100% | 75% | 50% | 50,000 | 15,000 | $65,000.00 | 50% | 50% | |
| (e.g) | Epidemiologist | 50% | 25% | 100% | 30,000 | 15,000 | $45,000.00 | 100% | ||
| 1 | $0.00 | |||||||||
| 2 | $0.00 | |||||||||
| 3 | $0.00 | |||||||||
| 4 | $0.00 | |||||||||
| 5 | $0.00 | |||||||||
| 6 | $0.00 | |||||||||
| 7 | $0.00 | |||||||||
| 8 | $0.00 | |||||||||
| 9 | $0.00 | |||||||||
| 10 | $0.00 | |||||||||
| Worksheet for recording percentage of time spent on each specific strategy, by each staff member, per award year | Year 1 (08/01/2021 - 07/31/2022) | Comments | |||||||||||
| Project Director | Epidemiologist | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Data and Surveillance | 25% | 100% | |||||||||||
| Collaborations and Partnerships | 25% | ||||||||||||
| Assessment and Evaluation | 50% | ||||||||||||
| Total | 100% | 100% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |
| Worksheet for recording percentage of time spent on each specific topic, by each staff member, per award year | Year 1 (08/01/2021 - 07/31/2022) | Comments | |||||||||||
| Project Director | Epidemiologist | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| ACEs | 25% | ||||||||||||
| Child Abuse and Neglect | 25% | ||||||||||||
| Intimate Partner/Sexual Violence | 50% | ||||||||||||
| Transportation Safety | |||||||||||||
| Traumatic Brain Injury | 100% | ||||||||||||
| Other (please specify) | |||||||||||||
| Total | 100% | 100% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | |
| Worksheet for Estimating Consultant Costs Per Award Year | ||||||||
| Year 1 (08/01/2021 - 07/31/2022) | Comments | |||||||
| Job Title | Description | Annual Payment | Strategy | % Time | Topic | % Time | ||
| (e.g.) | Software Developer | Developed internal progam software | $10,000 | Data and Surveillance | 60% | ACEs | 100% | |
| Assessment and Evaluation | 40% | |||||||
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| Total: | $0.00 | |||||||
| Worksheet for Estimating Contracts Per Award Year | |||||
| Year 1 (08/01/2021 - 07/31/2022) | Comments | ||||
| Type of Good/Service Purchased | Strategy | Topic | Amount ($) | ||
| (e.g.) Sub-award to University for evaluation | Assessment and Evaluation | ACEs | $30,000 | ||
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| 10 | |||||
| Total : | $0.00 | ||||
| Worksheet for Estimating Training and Material Costs Per Award Year | |||||||||
| Year 1 (08/01/2021 - 07/31/2022) | |||||||||
| Category | Type of Good/Service Purchased | # Units | Cost per Unit ($) | Total Cost | Total Cost (Enter total here only if units and cost per unit unknown) | Strategy | Topic | Comments | |
| Office Equipment | (e.g.) Dell Computers | 5 | $1,200.00 | $6,000.00 | $6,000.00 | All strategies | All Topics | ||
| Postage | (e.g.) Stamps | 500 | $0.45 | $225.00 | $225.00 | All strategies | All Topics | ||
| Software | (e.g) NVivo | 2 | $400.00 | $800.00 | $800.00 | Assessment and Evaluation | ACEs | ||
| Travel (Meetings/Conference/Training) | (e.g.) Travel to APHA | 2 | $1,500.00 | $3,000.00 | $3,000.00 | All strategies | Child Abuse and Neglect | ||
| Incentives/Stipends | (e.g) Gift Cards | 50 | $20.00 | $1,000.00 | $1,000.00 | Partnerships and Collaboration | Traumatic Brain Injury | ||
| Training Fees | (e.g.) ACEs Training | 1 | $300.00 | $300.00 | $300.00 | Data and Surveillance | All Topics | ||
| 1 | $0.00 | ||||||||
| 2 | $0.00 | ||||||||
| 3 | $0.00 | ||||||||
| 4 | $0.00 | ||||||||
| 5 | $0.00 | ||||||||
| 6 | $0.00 | ||||||||
| 7 | $0.00 | ||||||||
| 8 | $0.00 | ||||||||
| 9 | $0.00 | ||||||||
| 10 | $0.00 | ||||||||
| 11 | $0.00 | ||||||||
| 12 | $0.00 | ||||||||
| 13 | $0.00 | ||||||||
| 14 | $0.00 | ||||||||
| 15 | $0.00 | ||||||||
| 16 | $0.00 | ||||||||
| 17 | $0.00 | ||||||||
| 18 | $0.00 | ||||||||
| 19 | $0.00 | ||||||||
| 20 | $0.00 | ||||||||
| 21 | $0.00 | ||||||||
| 22 | $0.00 | ||||||||
| 23 | $0.00 | ||||||||
| 24 | $0.00 | ||||||||
| 25 | $0.00 | ||||||||
| Total : | $0.00 | ||||||||
| Worksheet for Estimating Local Transportation Costs Per Award Year | ||||||||
| Year 1 (08/01/2021 - 07/31/2022) | ||||||||
| Mode of Transportation | Event Description | Mileage (Cars only) | Rental Car Fee | Transit Fare/Parking Fee | Strategy | Topic | Total Cost | Comments |
| (e.g) Personal Vehicle | Training | 26.2 | $10.00 | All Strategies | All Topics | |||
| (e.g.) Train | Kick-off event | $5.00 | All Strategies | All Topics | ||||
| Total: | ||||||||
| Worksheet for Estimating Administrative (Overhead) Costs Per Award Year | ||||
| Year 1 (08/01/2021 - 07/31/2022) | Comments | |||
| 10A. Allocation Methodology | Y/N | % | $ Amount | |
| Proportion of direct cost? | ||||
| — Please indicate indirect cost rate (%) or dollar amount in column | ||||
| Lump-sum payment | ||||
| Other: specify | ||||
| Total : | $0.00 | |||
| 10B. If lump sum payment, indicate if the following costs are included in the administrative or overhead costs reported above. If these are paid for as specific line item charges in addition to the administrative costs, please provide the dollar amounts. | Y/N | If no, provide amount | $ Amount | |
| Rent for office space | ||||
| Utilities (Water, Gas, Electric) | ||||
| Repairs/maintenance | ||||
| Network connection/maintenance (i.e. internet connection charge) | ||||
| Phone Service (i.e. local phone service, long distance or cell phone charges) | ||||
| Shared office equipment | ||||
| Other costs: Specify | ||||
| Total : | $0.00 | |||
| Source: | ||||||
| Program Name: | Other Funding Sources: | Strategies: | Topics: | Personnel: | Training and Material Cost Categories: | Transportation Categories: |
| Arizona | Non-Core SIPP CDC Funds | Data and Surveillance | ACEs | Administrative Assistant | Capital materials (1-time expense or major purchase) | Bicycle/Scooter |
| Colorado | Non-CDC Federal Funds | Collaborations and Partnerships | Child Abuse and Neglect | AmeriCorps Volunteer | Contracts | Bus |
| Georgia | State Government Funds | Assessment and Evaluation | Intimate Partner/Sexual Violence | Community Health Liaison | Consultants | Personal Vehicle |
| Hawaii | City or County Funds | All Strategies | Transportation Safety | Community Health Worker | Continuing Education/Professional Development | Rental Car |
| Illinois | Private Grants | Traumatic Brain Injury | Community Outreach Coordinator | Curriculum/Educational Materials | Taxi/Uber/Lyft | |
| Kentucky | Corporate Sponsors/Donors | All Topics | Community Outreach Worker | Food and Drinks | Train | |
| Louisiana | Forfeiture Funds | Other (please specify) | Data Manager | Incentives/Stipends | ||
| Maryland | Other (please specify) | Data Specialist | Marketing/Promotional Materials | |||
| Massachusetts | Economist | Meeting Space | ||||
| Michigan | Epidemiologist | Membership Fees | ||||
| Minnesota | Evaluation Coordinator | Office Equipment | ||||
| Nebraska | Evaluator | Postage | ||||
| New York | Fellow | Small Office Supplies | ||||
| North Carolina | Health Educator | Software | ||||
| Oklahoma | Health Policy Analyst | Training Fees | ||||
| Ohio | Health Program Administrator | Translation Services | ||||
| Oregon | Health Program Coordinator | Transportation (local) | ||||
| Rhode Island | Injury Prevention Specialist | Travel (Meetings/Conferences/Trainings) | ||||
| Tennessee | Management Analyst | Other Supplies (please specify) | ||||
| Utah | Office Manager | |||||
| Virginia | Prevention Manager | |||||
| Washington | Program Aide | |||||
| Wisconsin | Program Assistant | |||||
| Program Director | ||||||
| Program Manager | ||||||
| Program Site Liaison | ||||||
| Program Specialist | ||||||
| Project Coordinator | ||||||
| Project Director | ||||||
| Project Manager | ||||||
| Public Health Specialist | ||||||
| Student Intern | ||||||
| Trainer | ||||||
| Violence Prevention Advocate | ||||||
| Violence Prevention Specialist | ||||||
| Youth Coordinator | ||||||
| Other (please specify) |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |