Form 0920-21GB Economic Indicators

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Overview

1. Program Details
2.Total Allocated Program Funds
3. In-Kind Contributions
4. Personnel
5. Personnel Strategies
6. Personnel Topics
7. Consultant Costs
8. Contracts
9. Training and Materials
10. Transportation
11. Administrative
Inputs

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Sheet 1: 1. Program Details

		Form Approved OMB NO: 0920-xxxx Exp. Date: X/XX/XXXX
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
Email
1C. Primary financial/administrative contact person
Name
Telephone
Email

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Sheet 2: 2.Total Allocated Program Funds

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.

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Sheet 3: 3. In-Kind Contributions

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
				$0.00
				$0.00
				$0.00
				$0.00
				$0.00
				$0.00
				$0.00
				$0.00
				$0.00
				$0.00
				$0.00
				$0.00
Total:			$0.00	$0.00
Total Year 1:				$0.00

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Sheet 4: 4. Personnel

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

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Sheet 5: 5. Personnel Strategies

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%

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Sheet 6: 6. Personnel Topics

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%

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Sheet 7: 7. Consultant Costs

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%
1
2
3
4
5
6
7
8
9
10
		Total:	$0.00

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Sheet 8: 8. Contracts

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
1
2
3
4
5
6
7
8
9
10
		Total :		$0.00

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Sheet 9: 9. Training and Materials

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

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Sheet 10: 10. Transportation

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:

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Sheet 11: 11. Administrative

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

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Sheet 12: Inputs

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)