Non-Labor Cost Questionnaire

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Red Carpet Entry (RCE) Program Implementation Project

Attachment # 3h

Labor Cost Questionnaire

Public reporting burden of this collection of information is estimated to average 90 minutes 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)

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

RCE Cost Data Collection Instrument: Labor/Personnel Questionnaire

Non-Research Costs

Note: A separate form must be completed for each clinic staff member working on the RCE intervention.

1. Select your clinic:

   1. Rutgers Infectious Diseases Clinic

   2. Florida Department of Health in Hillsborough County

2. Job title: ______________________________________________

3. Month and Year of Time Reporting (mm/yyyy): ­­­­­­­­­­_________________________________

4. Is your work on the RCE intervention paid by RCE funds? ____Yes ____No

For the month entered above, think of a typical week that you spent at work. In that typical week, how much time did you spend on each of the activities outlined below.

Note: Do NOT report time spent on research activities or the time spent on consenting patients to provider their appointment data. Do NOT leave any of the boxes blank. Enter “0” in the Hours and Minutes boxes if you did not spend time on the activity.

Public reporting burden of this collection of information is estimated to average 90 minutes 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)

[Preparation Phase]

#	Activity	Time/Week
1	Staff training and preparation: activities may include (a) recruitment, (b) hiring, (c) training, (d) supervision, and (e) management of internal program staff.	___Hrs ___Mins
2	Establishing referral network: activities may include (a) training of or (b) coordination with the internal or external CTR counselors and partner organizations.	___Hrs ___Mins
3	Administration/general oversight: activities may include (a) project management and coordination, (b) attendance at meetings devoted to RCE, (c) placing orders for office supplies, and (d) any other RCE work that is not captured by activities above.  Note, costs associated with research/evaluation should NOT be reported for this study.	___Hrs ___Mins
	Total:

[Implementation Phase]

#	Activity	Time/Week
1	Staff training and preparation: activities may include (a) recruitment, (b) hiring, (c) training, (d) supervision, and (e) management of internal program staff.	___Hrs ___Mins
2	Referral processing: activities may include receiving and discussing referrals with external and internal CTR counselors.	___Hrs ___Mins
3	Intervention delivery: activities may include (a) interacting with patients who are attending their RCE appointment, (b) facilitating warm handoffs between care providers, and (c) other activities associated with delivering the RCE intervention. Time associated with consenting patients to provide their appointment data should NOT be included here.	___Hrs ___Mins
4	RCE Outreach and Reengagement: activities may include (a) identifying patients who need to receive RCE outreach (i.e., they did not attend their RCE appointment or have not yet responded to the RCE concierge’s attempt to establish contact to schedule the RCE appointment), (b) conducting outreach following the RCE Outreach and Reengagement, or (c) communicating with internal or external CTR counselors as part of the RCE outreach process.	___Hrs ___Mins
5	Report cards: activities may include time spent reviewing report cards and discussing results with other staff.	___Hrs ___Mins
6	Administration/general oversight: activities may include (a) project management and coordination, (b) attendance at meetings devoted to RCE, (c) placing orders for office supplies, and (d) any other RCE work that is not captured by activities above.  Note, costs associated with research/evaluation should NOT be reported for this study.	___Hrs ___Mins
	Total: