Form 0920-24FI Comprehensive Evaluation Resource Use and Cost Inventory
[NCCHPHP] Comprehensive Evaluations of theDP-23-003, DP-23-004, and DP-23-0005 Cooperative Agreement Programs: The National Cardiovascular Health Program, The Innovative Cardiovascular Health Program
Att 5a. Comprehensive Evaluation_Resource Use and Cost Inventory Tool_Recipients.xlsx
Comprehensive Evaluation Resource Use and Cost Inventory Tool_Recipient (Attachment 5a)
OMB: 0920-1453
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-1453 can be found here:
Document [xlsx]
Download: xlsx | pdf
Instructions
Component Totals
Parameters
Personnel
Contractors and Subcontractors
Facilities and Utilities
Equipment, Supplies, Materials
Travel
Other Funding Sources
Other Costs and Resources
Overview
Cover pageInstructions
Component Totals
Parameters
Personnel
Contractors and Subcontractors
Facilities and Utilities
Equipment, Supplies, Materials
Travel
Other Funding Sources
Other Costs and Resources
Sheet 1: Cover page
| Form Approved OMB No. 0920-XXXX Exp. Date xx/xx/20xx |
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| [Cooperative Agreement]: Resource Use and Cost Inventory Tool | |||
| Introduction to Cost Study | |||
| Thank you for taking the time to complete this Resource Use and Cost Inventory tool. Please follow the instructions in this tool to provide cost data related to the implementation and operation of the <insert Cooperative Agreement>. The data collected with this tool will be used to (1) estimate the overall costs of implementing the <insert Cooperative Agreement> and (2) determine the costs of implementation by different cost categories (personnel, supplies, etc.). Completion of this Resource Use and Cost Inventory Tool is voluntary and it will not in any way impact the funding or technical assistance you receive from CDC. You will spend approximately 2.5 hours completing the tool, including time to retrieve information you may need to fill the form. You may save a partially completed tool and return to complete it at a different time. Review the Instructions page for additional information on completing this tool. The Comprehensive Evaluation Team is available to address any questions you may have and provide additional guidance to support completion of this this tool. You may email the Comprehensive Evaluation Team, [email protected] with questions. |
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| Note: Public reporting burden of this collection of information is estimated to average 2.5 hours 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: PRA (0920-24XXX) | |||
Sheet 2: Instructions
| [Cooperative Agreement: Resource Use and Cost Inventory Tool | ||||||
| Introduction to Cost Study | ||||||
| Thank you for taking the time to participate in the <insert Cooperative Agreement> Resource Use and Cost Inventory Tool. We are conducting a program cost analysis, which estimates the overall costs of implementing the program. You will spend approximately 2.5 hours completing the tool, including time to retrieve information you may need to fill the form. You will have until {cost tool close date} to submit your response. Your participation in this program cost analysis is completely voluntary and it will not in any way impact the funding or technical assistance you receive from CDC. If you have any questions about the study or the tool, please contact the Comprehensive Evaluation Team, [email protected]. Note: Public reporting burden of this collection of information is estimated to average 2.5 hours 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. |
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| Instructions | ||||||
| Each of the corresponding worksheets have their own specific instructions. Note that boxes shaded in yellow do not need to be filled out by the respondent as these cells will automatically populate based on the Excel formula within these cells. Some information and costs have been pre-populated with data based on documents submitted to the CDC. Please review and adjust any data that is incorrect for your organization. To support your review and completion of each tab, it may be helpful to have the following information readily available for the <insert Cooperative Agreement reporting period>: 1) CDC budget documents (Budget narrative, budget markup, FFR) 2) Workplans 3) APRs 4) Other recipient/partner documents that describe implementation 5) Other recipient/partner documents that describe costs or resources used for each sub-strategy |
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| Key Program Activities by Sub-strategy | ||||||
| Below is a summary of the program activities for each sub-strategy you are implementing during <Program Year 1/Program Year 2>. Please refer back to this list as you review and input data throughout this tool. Please adjust the descriptions if needed to capture additional detail important to understand the implementation costs and resources reported. [Note the following list of sub-strategies will be updated and tailored for each cooperative agreement and recipient] | ||||||
| 1A: Summary of Sub-strategy 1A activities | ||||||
| 1B: Summary of Sub-strategy 1B activities | ||||||
| 1C: Summary of Sub-strategy 1C activities | ||||||
| 1D: Summary of Sub-strategy 1D activities | ||||||
| 1E: Summary of Sub-strategy 1E activities | ||||||
| 2A: Summary of Sub-strategy 2A activities | ||||||
| 2B: Summary of Sub-strategy 2B activities | ||||||
| 2C: Summary of Sub-strategy 2C activities | ||||||
| 3A: Summary of Sub-strategy 3A activities | ||||||
| 3B: Summary of Sub-strategy 3B activities | ||||||
| 3C: Summary of Sub-strategy 3C activities | ||||||
| 3D: Summary of Sub-strategy 3D activities | ||||||
| Suggestion for Ease of Use | ||||||
| To freeze header rows for improved table readability and cell navigation as you scroll: | ||||||
| 1. Find the table that you want to "freeze" so that you can always see the first column and the first row (the row with colorful heading) as you move the left and right on the sheet. | ||||||
| 2. Select the cell in the first row and the first column of the table as shown by the highlighted cell in the example here. | ||||||
| 3. Select the view tab, then Freeze Panes as highlighted below: | ||||||
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| 4. Check that it worked by scrolling left to right, then up and down in the table. The first row and the first column should now always visible as you scroll. | ||||||
Sheet 3: Component Totals
| [Cooperative Agreement]: Resource Use and Cost Inventory Tool | |||||
| Resource Totals | |||||
| Instructions: Recipient, Reporting Period, and Cost Study Component information on this page has been pre-populated. Items in yellow (Totals) will automatically be populated due to the Excel formula within each cell. Totals will update as you complete the tool. There is no need to fill out any of the information listed on this page. | |||||
| Recipient | |||||
| Reporting Period | |||||
| $623,574.09 | |||||
| Total <insert Cooperative Agreement> Spending Amount | |||||
| Tabs | Cost Study Component | Total | |||
| 1 | Parameters | N/A | |||
| 2 | Personnel | $156,000.00 | |||
| 3 | Contractors and Subcontractors | $445,000.00 | |||
| 4 | Facilities and Utilities | $16,380.00 | |||
| 4 | Equipment, Supplies, Materials | $6,194.09 | |||
| 5 | Travel | $- | |||
| 6 | Other Funding Sources | N/A | |||
| 7 | Other Costs and Resources | $- | |||
Sheet 4: Parameters
| [Cooperative Agreement]: Resource Use and Cost Inventory Tool | |||||
| Parameters | |||||
| Instructions: Recipient, Reporting Period, and Total [insert Cooperative Agreement] Funding Amount in yellow will automatically be populated due to the Excel formula within each cell. For the table, review the sub-strategies your program is implementing (Column A). For each sub-strategy, please identify the level of maturity of sub-strategy (column E) using the drop-down. Level of maturity of sub-strategy drop-down options include Development, Start-up, Growth, Expansion, and Maintenance. These are defined as follows: Development: sub-strategy is under the design phase (0% mature); Start-up: initiation of sub-strategy for the first time under the <insert Cooperative Agreement> (25% mature); Growth: sub-strategy is gaining traction, increasing number of sites, participation from target audience (50% mature); Expansion: sub-strategy has not only gained traction but has now expanded to desired size and reach (75% mature); Maintenance: continuation of sub-strategy under <insert Cooperative Agreement> perhaps under another NOFO or initiative, activities are established (100% mature). |
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| - | |||||
| Recipient | |||||
| - | |||||
| Reporting Period | |||||
| $623,574.09 | |||||
| Total <insert Cooperative Agreement> Funding Amount | |||||
| The National CVH Program | |||||
| Is the recipient implementing this sub-strategy? | (Yes/No) (Dropdown) |
Level of Maturity of Sub-strategy (Dropdown) |
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| 1A | Advance the adoption and use of electronic health records (EHR) or health information technology (HIT), to identify, track, and monitor measures for clinical and social services and support needs to address health care disparities and health outcomes for patients at highest risk of cardiovascular disease (CVD) with a focus on hypertension and high cholesterol. | Yes | |||
| 1B | Promote the use of standardized processes or tools to identify the social services and support needs of patient populations at highest risk of CVD, with a focus on hypertension and high cholesterol, and monitor and assess the referral and utilization of those services, such as food assistance, transportation, housing, childcare, etc. | Yes | |||
| 2A | Advance the use of health information systems that support team-based care to monitor population health with a focus on health disparities, hypertension, and high cholesterol | Yes | |||
| 2B | Assemble or create multidisciplinary teams (e.g., nurses, nurse practitioners, pharmacists, nutritionists, physical therapists, social workers, and community-based workers) to identify patients' social services and support needs and to improve the management and treatment of hypertension and high cholesterol. | Yes | |||
| 2C | Build and manage a coordinated network of Multidisciplinary partnerships that address identified barriers to social services and support needs (e.g., childcare, transportation, language translation, food assistance, and housing) within populations at highest risk of CVD | Yes | |||
| 3A | Create and enhance community-clinical links to identify SDOH (e.g., inferior housing, lack of transportation, inadequate access to care, and limited community resources) and respond to the social services and support needs of populations at highest risk of CVD with a focus on hypertension and high cholesterol. | Yes | |||
| 3B | Identify and deploy dedicated CHWs (or their equivalents) to provide a continuum of care and services which extend the benefits of clinical interventions and address social services and support needs leading to optimal health outcomes | Yes | |||
| 3C | Promote use of self-measured blood pressure monitoring (SMBP) with clinical support within populations at highest risk of hypertension | Yes | |||
| The Innovative CVH Program | |||||
| Is the recipient implementing this sub-strategy? | (Yes/No) (Dropdown) |
Level of Maturity of Sub-strategy (Dropdown) |
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| 1A | Advance the adoption and use of electronic health records (EHR) or health information technology (HIT), to identify, track, and monitor measures for clinical and social services and support needs to address health care disparities and health outcomes within approved populations of focus. | Yes | |||
| 1B | Promote the use of standardized processes or tools to identify the social services and support needs of patient populations at highest risk of CVD, with a focus on hypertension and high cholesterol, and monitor and assess the referral and utilization of those services, such as food assistance, transportation, housing, childcare, etc. | Yes | |||
| 2A | Advance the use of health information systems that support team-based care to monitor and address hypertension and high cholesterol within approved populations of focus. | Yes | |||
| 2B | Assemble or create multidisciplinary teams to identify social services and support needs within approved populations of focus. | Yes | |||
| 2C | Build and manage a coordinated network of multidisciplinary partnerships that address identified barriers and needs within approved populations of focus, related to their social services and support needs (e.g., childcare, transportation, language translation, food assistance, and housing). | Yes | |||
| 3A | Create and enhance community-clinical links to identify SDOH (e.g., housing, transportation, access to care, and community resources) and respond to the individual social services and support needs within approved populations of focus. | Yes | |||
| 3B | Identify and deploy dedicated CHWs (or their equivalents) to provide a continuum of care and services which extend the benefits of clinical interventions and address social needs leading to optimal health outcomes within approved populations of focus. | Yes | |||
| 3C | Promote use of self-measured blood pressure monitoring (SMBP) with clinical support within approved populations of focus. | Yes | |||
| WISEWOMAN | |||||
| Is the recipient implementing this sub-strategy? | (Yes/No) (Dropdown) |
Level of Maturity of Sub-strategy (Dropdown) |
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| 1A | Provide cardiovascular disease (CVD) risk assessment to under- and uninsured participants in the priority age range of 35- 64 years during the baseline, follow-up, and reassessment office visits, as appropriate. | Yes | |||
| 1B | Use electronic health record (EHR) and health information technology (HIT) data to query, monitor, and track clinical and social services and support needs data for improved identification, management, referrals, treatment, and outcomes of those at risk of CVD, particularly hypertension. | Yes | |||
| 1C | Use standardized procedures to identify social services and support needs of participants and monitor and assess the referral and utilization of those services, such as food assistance, transportation, housing, childcare, etc. | Yes | |||
| 1D | Use metrics from program data to guide quality improvement activities, e.g., Plan Do Study Act (PDSA) cycles, participant and partner feedback, etc., to increase program enrollment, retention, and referrals to additional services. | Yes | |||
| 1E | Use EHR, HIT or program data to identify health care disparities and address health outcomes within their WISEWOMAN population. | Yes | |||
| 2A | Engage program participants, health professionals, community health workers, social workers, patient navigators, pharmacists, and other members of the care team in community settings outside of health care facilities to enhance participant follow-up and communication and coordination among the care team. | Yes | |||
| 2B | Build and maintain a network of state, regional, and local social services and support based on social determinants of health within the recipient’s jurisdiction. | Yes | |||
| 3A | Identify, enhance, or build systems that facilitate provider and community bidirectional referrals to support medical follow-up, healthy behavior support services (HBSS), and social services and support. | Yes | |||
| 3B | Collaborate with community groups who represent and serve the priority population, provide evidence-informed HBSS, and refer participants to those HBSS. | Yes | |||
| 3C | Use evidence-based and evidence-informed strategies to ensure participants are actively engaged in HBSS. | Yes | |||
| 3D | Refer participants to appropriate social services and support; track and monitor use. | Yes | |||
Sheet 5: Personnel
| [Cooperative Agreement]: Resource Use and Cost Inventory Tool | ||||||||||||||||||||||||||||||||||||
| Personnel Costs | ||||||||||||||||||||||||||||||||||||
| Instructions: Recipient, Reporting Period, Total Personnel Costs, and items in yellow will automatically be populated due to the Excel formula within each cell. Please fill out the information in the table by listing the job titles for those working on the <insert Cooperative Agreement> within Column B, starting in row 18. Insert extra rows if there is not enough space to list all staff positions. Please list the actual monthly salary of the specific individual that holds that current position. Please identify the percent of time allocated for work on the <insert Cooperative Agreement> sub-strategies. If staff do not have benefits (i.e. are temporary) please write 0 for their benefits. Use the box below the table to provide additional information or clarification of personnel costs/categories not accounted for in the table. |
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| Recipient: | - | |||||||||||||||||||||||||||||||||||
| Reporting Period: | - | 1 | ||||||||||||||||||||||||||||||||||
| Total Personnel Costs: | $156,000.00 | |||||||||||||||||||||||||||||||||||
| List names of all staff positions (insert extra rows if there is not enough space to list all staff positions) | ||||||||||||||||||||||||||||||||||||
| Job Title (Write-In) |
Full-Time Employee (FTE), Part-Time Employee (PTE), In-Kind or Volunteer Contribution (Dropdown) |
Actual monthly salary for job title (Write-in) |
Average monthly benefits for job title (Write-in) |
Total Personnel Costs (Monthly) | Start date of job position (month and year) during <insert Cooperative Agreement> reporting period (Write-in) | Is this a new position for <insert Cooperative Agreement> ? (Yes/No) (Dropdown) |
# months worked on <insert Cooperative Agreement> during reporting period (Dropdown) | Total Personnel Costs (Annually) | # months position has been vacant in last 12 months (Dropdown) | Total # years expected to work on <insert Cooperative Agreement> during reporting period (Dropdown) | Total # of hours per week allocated to working on <insert Cooperative Agreement> (Write-In) | Annual % time dedicated to <insert Cooperative Agreement> (Write-In) |
Avg # hours dedicated to <insert Cooperative Agreement>/wk | Based on the average hours dedicated to <insert Cooperative Agreement> (in Column O), what is the estimated percent of time allocated to each sub-strategy over the course of the reporting period. Note: If the staff member's time is allocated across multiple sub-strategies, provide the best estimate for each sub-strategy. If the staff member's time is allocated equally across multiple sub-strategies, divide their total time equally across each sub-strategy they worked on. Use 0% for any sub-strategy the staff member did not work on during the reporting period. (Write-In) |
Total Personnel Costs (Annually) per sub-strategy | |||||||||||||||||||||
| 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | |||||||||||||||
| Program Director | FTE | $6,000.00 | $1,000.00 | $7,000.00 | September-2024 | No | 12 | $84,000.00 | - | 20% | 20% | 0% | 0% | 20% | 20% | 0% | 20% | 20% | 0% | 0% | $16,800.00 | $16,800.00 | $- | $- | $16,800.00 | $16,800.00 | $- | $16,800.00 | $16,800.00 | $- | $- | |||||
| Health System Coordinator | FTE | $4,000.00 | $2,000.00 | $6,000.00 | September-2024 | No | 12 | $72,000.00 | - | 50% | 50% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | $36,000.00 | $36,000.00 | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| $- | $- | - | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||
| TOTAL | N/A | $10,000.00 | $3,000.00 | $13,000.00 | N/A | N/A | N/A | $156,000.00 | N/A | N/A | N/A | N/A | - | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 52,800.00 | 52,800.00 | - | - | 16,800.00 | 16,800.00 | - | 16,800.00 | 16,800.00 | - | - | |
| Provide additional information or clarification here: | ||||||||||||||||||||||||||||||||||||
Sheet 6: Contractors and Subcontractors
| [Cooperative Agreement]: Resource Use and Cost Inventory Tool | |||||||||||||||||||||||||||||
| Contractors, Subcontractors, Consultants, and Other Partners | |||||||||||||||||||||||||||||
| Instructions: Recipient, Reporting Period, Total Costs and items in yellow will automatically be populated due to the Excel formula within each cell. Please fill out the information in the table by first filling out the name of the contractor/subcontractor/consultant/other partner starting in column B, row 17. After identifying the individuals or firms who are being paid to implement <insert Cooperative Agreement> work, use the dropdown menu in each cell of column C and column D to select whether the entity being paid to implement the work is a contractor/subcontractor/consultant/other partner and their method for selection. For column F please fill out the corresponding values. For columns I-S, please select the sub-strategies the contractor has been paid to implement. Insert extra rows if there is not enough space to report all contractors, subcontractors, consultants and other partners. |
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| Recipient: | - | ||||||||||||||||||||||||||||
| Reporting Period: | - | ||||||||||||||||||||||||||||
| Total Costs for Contractors, Subcontractors, Consultants, and Other Partners: | $445,000.00 | ||||||||||||||||||||||||||||
| List names of all contractors, subcontractors, consultants or other partner (insert extra rows if there is not enough space) | Provide an estimate for the percent of funding allocated to each sub-strategy over the course of the reporting period. Note: If the entity supported multiple sub-strategies, provide the best estimate for each sub-strategy. If the entity supported all sub-strategies equally, divide the total amount equally across each sub-strategy they worked on. Use 0% for any sub-strategy the entity did not support during the reporting period. (Write-In) |
Total Contractors, Subcontractors, Consultants, Other Partner Costs (Annually) per sub-strategy | |||||||||||||||||||||||||||
| Name of Contractor/Subcontractor/Consultant/Other partner | Type of entity paid to implement activity (Dropdown) | Method of Selection for Contractor, Subcontractor, or Partner (Sole Source/Competed) (Dropdown) |
Total Award Amount (Annual) | Total Amount Spent to Date (Annual) |
Total Amount Unspent (Annual) | # of sub-strategies implemented (calculated) |
1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | |
| Partner Clinic City #1 | Contractor | Sole Source | $160,000.00 | $150,000.00 | $10,000.00 | 2 | 50% | 50% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 0% | $80,000.00 | $80,000.00 | $- | $- | $- | $- | $- | $- | $- | $- | $- | |
| University Partner | Contractor | Sole Source | $125,000.00 | $125,000.00 | $0.00 | 3 | 0% | 0% | 0% | 0% | 0% | 0% | 0% | 25% | 25% | 25% | 25% | $- | $- | $- | $- | $- | $- | $- | $31,250.00 | $31,250.00 | $31,250.00 | $31,250.00 | |
| Pharmacy Association | Contractor | Sole Source | $60,000.00 | $60,000.00 | $0.00 | 1 | 0% | 0% | 0% | 0% | 0% | 100% | 0% | 0% | 0% | 0% | 0% | $- | $- | $- | $- | $- | $60,000.00 | $- | $- | $- | $- | $- | |
| Pharmacy Site | Subcontractor | Sole Source | $100,000.00 | $50,000.00 | $50,000.00 | 1 | 0% | 0% | 0% | 0% | 0% | 100% | 0% | 0% | 0% | 0% | 0% | $- | $- | $- | $- | $- | $100,000.00 | $- | $- | $- | $- | $- | |
| $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 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||
| TOTAL | N/A | N/A | $445,000.00 | $385,000.00 | $60,000.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | 80,000.00 | 80,000.00 | - | - | - | 160,000.00 | - | 31,250.00 | 31,250.00 | 31,250.00 | 31,250.00 | ||
| Provide additional information or clarification here: | |||||||||||||||||||||||||||||
Sheet 7: Facilities and Utilities
| [Cooperative Agreement]: Resource Use and Cost Inventory Tool | ||||||||||||||||||||||||||||||||
| Buildings, Facilities, Utilities | ||||||||||||||||||||||||||||||||
| Instructions: Recipient, Reporting Period, Total Costs and items in yellow will automatically be populated due to the Excel formula within each cell. Examples of office and facility-related expenditures are provided in Table 1 (starting at row 20). In the column for Space in Building/Facility, please provide overall square footage if available. If annual cost per unit of building/facility expenditure is not available, please provide the name of city/town the site is located so that the evaluation team can estimate value of space/utility by using the commercial rates within a given area. Please add additional items to Table 1 as needed. |
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| Recipient: | - | |||||||||||||||||||||||||||||||
| Reporting Period: | - | |||||||||||||||||||||||||||||||
| Total Costs for Buildings & Facilities: | $16,380.00 | |||||||||||||||||||||||||||||||
| Table 1. Building-, Facility-, and Utility-Related Expenditures | ||||||||||||||||||||||||||||||||
| The items below are examples of building/facility related expenditures - please update with additional building/facility expenditures and per each site. | ||||||||||||||||||||||||||||||||
| Site (e.g., Recipient organization locations, Partner sites) | Type of Building/Facility Expense | Annual Cost per Unit | Quantity (Annually) | Space in Building/Facility (Sq. ft) | % of Space used for Program Activities | Total costs (Annual) | Sq. Footage used for Program Activities | Name of City/Town, State (fill only if facility cost is not available) | Comments | Provide an estimate for the percent of facilitates/utilities costs associated with each sub-strategy during the reporting period. Note: If the site costs align with multiple sub-strategies, provide the best estimate for each sub-strategy. If the site costs align with all sub-strategies equally, divide the total amount equally across each sub-strategy. Use 0% for any sub-strategy that is not applicable for the facility/utility cost.. (Write-In) |
Total Facilities Costs (Annually) per sub-strategy | |||||||||||||||||||||
| 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | |||||||||||
| Site 1 | e.g. Office rental | $18,000.00 | 1 | 1500 | 40% | $7,200.00 | 600 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||
| Site 1 | e.g. Office phone/internet utilities | $1,200.00 | 1 | 1500 | 40% | $480.00 | 600 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||
| Site 1 | e.g. Office water/electricity utilities | $2,500.00 | 5 | 1500 | 40% | $5,000.00 | 600 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||
| Site 1 | e.g. Annual maintenance/repair | $1,500.00 | 5 | 1500 | 40% | $3,000.00 | 600 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||
| Site 2 | e.g. Office space | NA | 1 | 2000 | 10% | $- | 200 | Birmingham, AL | Monthly cost not available, facility space is provided in-kind | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||
| Site 2 | e.g. Office phone/internet utilities | $1,800.00 | 1 | 2000 | 10% | $180.00 | 200 | Birmingham, AL | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||
| Site 2 | e.g. Office water/electricity utilities | $3,200.00 | 1 | 2000 | 10% | $320.00 | 200 | Birmingham, AL | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||
| Site 2 | e.g. Annual maintenance/repair | $2,000.00 | 1 | 2000 | 10% | $200.00 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||
| TOTAL | N/A | N/A | N/A | N/A | N/A | $16,380.00 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | - | - | - | - | - | - | - | - | - | - | - | |
Sheet 8: Equipment, Supplies, Materials
| [Cooperative Agreement]: Resource Use and Cost Inventory Tool | |||||||||||||||||||||||||||||||||
| Equipment, Supplies, Materials | |||||||||||||||||||||||||||||||||
| Instructions: Recipient, Reporting Period, and Total Costs and items in yellow will automatically be populated due to the Excel formula within each cell. Please fill out Tables 1-3 below. For Table 1 (starting at row 20), some office equipment and non-medical items are provided for guidance; for Table 2 (starting at row 36), some medical equipment and health-related items are provided; and for Table 3 (starting at row 54), some in-kind contribution items are provided. If the equipment is a long-term asset (has a useful life greater than one year), please provide additional information on acquisition of asset and estimated years of useful life to facilitate calculations of depreciation. Fill in columns colored green based on whether the asset is long-term or short-term. <For WISEWOMAN recipients, Table 2 should also include HBSS cost breakdowns>. Please add additional items to Tables 1-3 as needed. |
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| Recipient: | - | ||||||||||||||||||||||||||||||||
| Reporting Period: | - | ||||||||||||||||||||||||||||||||
| Total Costs for Equipment & Supplies: | $6,194.09 | ||||||||||||||||||||||||||||||||
| Table 1. Office Equipment and Non-medical Expenditures | |||||||||||||||||||||||||||||||||
| Office equipment is defined as assets such as computers, printers, copiers, paper, cartridges, etc. The items below are examples of office equipment - please update with office equipment used. | |||||||||||||||||||||||||||||||||
| Resource/Equipment | Long-Term Asset? (use for >1 year?) | INSTRUCTION: FILL COLUMNS HIGHLIGHTED GREEN BELOW BASED ON WHETHER EQUIPMENT IS LONG-TERM: | Quantity (Annually) | Site (e.g., Recipient organization, Partner site) | Annuity Factor | Total costs (Annual) | Comments | Provide an estimate for the percent of resource/equipment costs associated with each sub-strategy during the reporting period. Note: If the resource/equipment costs align with multiple sub-strategies, provide the best estimate for each sub-strategy. If the equipment costs align with all sub-strategies equally, divide the total amount equally across each sub-strategy. Use 0% for any sub-strategy that is not applicable for the resource/equipment cost. (Write-In) |
Total Equipment/Resource Costs (Annually) per sub-strategy | ||||||||||||||||||||||||
| Total Years of Useful Life (if equipment is long-term) | Purchase Price (if equipment is long-term) | Annual maintenance costs (if equipment is long-term) | Annual Cost per Unit (if equipment is NOT long-term) | ||||||||||||||||||||||||||||||
| 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | ||||||||||||
| e.g. Laptop computer | Yes | 6 | $1,200.00 | $20.00 | 12 | Site 1 | 5.08 | $3,077.05 | |||||||||||||||||||||||||
| e.g. Desktop computer | Yes | 8 | $900.00 | $10.00 | 5 | Site 1 | 6.46 | $746.25 | |||||||||||||||||||||||||
| e.g. Ink cartridge | No | $12.00 | 5 | Site 2 | 0.00 | $60.00 | |||||||||||||||||||||||||||
| e.g. Paper | No | $0.05 | 1500 | Site 2 | 0.00 | $75.00 | |||||||||||||||||||||||||||
| 0.00 | $- | ||||||||||||||||||||||||||||||||
| 0.00 | $- | ||||||||||||||||||||||||||||||||
| 0.00 | $- | ||||||||||||||||||||||||||||||||
| 0.00 | $- | ||||||||||||||||||||||||||||||||
| 0.00 | $- | ||||||||||||||||||||||||||||||||
| TOTAL | N/A | N/A | $3,958.30 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | - | - | - | - | - | - | - | - | - | - | - | |||||||
| Table 2. Medical Equipment and Health-Related Expenditures | |||||||||||||||||||||||||||||||||
| Medical equipment is defined as devices or tools used in the provisioning of health care services. The items below are examples of medical equipment - please update with key medical equipment used. | |||||||||||||||||||||||||||||||||
| Resource/Equipment <For WISEWOMAN recipients, this will include HBSS cost breakdowns> | Long-Term Asset? (use for >1 year?) | INSTRUCTION: FILL COLUMNS HIGHLIGHTED GREEN BELOW BASED ON WHETHER EQUIPMENT IS LONG-TERM: | Quantity (Annually) | Site (e.g., Recipient organization, Partner site) | Annuity Factor | Total costs (annual) | Comments | Provide an estimate for the percent of resource/equipment costs associated with each sub-strategy during the reporting period. Note: If the resource/equipment costs align with multiple sub-strategies, provide the best estimate for each sub-strategy. If the equipment costs align with all sub-strategies equally, divide the total amount equally across each sub-strategy. Use 0% for any sub-strategy that is not applicable for the resource/equipment cost. (Write-In) |
Total Equipment/Resource Costs (Annually) per sub-strategy | ||||||||||||||||||||||||
| Total Years of Useful Life (if equipment is long-term) | Purchase Price (if equipment is long-term) | Annual maintenance costs (if equipment is long-term) | Annual Cost per Unit (if equipment is NOT long-term) | ||||||||||||||||||||||||||||||
| 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | ||||||||||||
| e.g.stethoscope | Yes | 10 | $150.00 | $- | 3 | 7.72 | $58.28 | ||||||||||||||||||||||||||
| e.g.echocardiogram | Yes | 15 | $1,400.00 | $12.00 | $- | 4 | 10.38 | $587.52 | |||||||||||||||||||||||||
| e.g.electrocardiogram | No | $1,500.00 | 1 | Site 1 | 0.00 | $1,500.00 | |||||||||||||||||||||||||||
| e.g.screening materials | No | $- | 0.00 | $- | |||||||||||||||||||||||||||||
| e.g.stress test equipment | No | $- | 0.00 | $- | |||||||||||||||||||||||||||||
| e.g.(clinic) blood pressure monitors | Yes | $75.00 | 15 | Site 2 | 0.00 | $- | |||||||||||||||||||||||||||
| e.g.(patient) blood pressure cuffs | No | $30.00 | 3 | Site2 | 0.00 | $90.00 | |||||||||||||||||||||||||||
| 0.00 | $- | ||||||||||||||||||||||||||||||||
| 0.00 | $- | ||||||||||||||||||||||||||||||||
| 0.00 | $- | ||||||||||||||||||||||||||||||||
| 0.00 | $- | ||||||||||||||||||||||||||||||||
| TOTAL | N/A | N/A | N/A | $2,235.79 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | - | - | - | - | - | - | - | - | - | - | - | ||||||
| Table 3. In-Kind Contributions | |||||||||||||||||||||||||||||||||
| Resource/Equipment | Quantity (annual) | % of Time in Year item/resource is made available (if applicable) | Site (e.g., Recipient organization, Partner site) | Description of In-Kind Contribution | Provide an estimate for the percent of resource/equipment costs associated with each sub-strategy during the reporting period. Note: If the resource/equipment costs align with multiple sub-strategies, provide the best estimate for each sub-strategy. If the equipment costs align with all sub-strategies equally, divide the total amount equally across each sub-strategy. Use 0% for any sub-strategy that is not applicable for the resource/equipment cost. (Write-In) |
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| 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | |||||||||||||||||||||||
| e.g. Transport Vouchers | 50 | ||||||||||||||||||||||||||||||||
| e.g. blood pressure cuffs | 1 | ||||||||||||||||||||||||||||||||
| TOTAL | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | ||||||||||||||||||
Sheet 9: Travel
| [Cooperative Agreement]: Resource Use and Cost Inventory Tool | |||||||||||||||||||||||||||||||||||||||||||||
| Travel Costs | |||||||||||||||||||||||||||||||||||||||||||||
| Instructions: Recipient, Reporting Period, and Total Costs and items in yellow will automatically be populated due to the Excel formula within each cell. Please fill out the following table for <insert Cooperative Agreement>-related travel only. Travel for <insert Cooperative Agreement> may include, but is not limited to: conferences where the attendee is attending/presenting for <insert Cooperative Agreement>; site visits; meetings with sites, partners, etc. For columns Y to AI please indicate whether the travel supported any of the <insert Cooperative Agreement> sub-strategies. |
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| Recipient: | - | ||||||||||||||||||||||||||||||||||||||||||||
| Reporting Period: | - | ||||||||||||||||||||||||||||||||||||||||||||
| Total Travel Costs: | $0.00 | ||||||||||||||||||||||||||||||||||||||||||||
| Conference | Car Travel | Air Travel | Lodging | Per Diem | Other Ground Transportation | Other Travel Costs | TOTAL TRAVEL COSTS | Did travel support any of these sub-strategies? (Yes/No) (Dropdown) |
Total Travel Costs per sub-strategy | ||||||||||||||||||||||||||||||||||||
| Purpose of travel (Write-In) |
Does travel coincide with [complementary Cooperative Agreement] travel? (Yes/No) (Dropdown) |
In-state/ out of state travel? (Dropdown) |
Recipient traveled to (if applicable) (Write-In) |
# of [cooperative agreement]-funded staff traveling (Dropdown) |
Conference Registration Fees (if applicable) (Write-In) |
Total Conference Registration Fees | If Driving - Total number of miles (Write-In) |
Cost per mile (Write-In) |
Total ground travel | Cost of airfare (unit cost) (Write-In) |
Total Air Travel | Hotel cost per night (Write-In) |
Number of nights (Write-In) |
Total Lodging | Per Diem rate (Write-In) |
Number of days (Write-In) |
Total Per Diem | Unit cost (Write-In) |
Total cost |
Other travel costs (Write-In) |
Total other costs | 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | ||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||||||||||||||||
| TOTAL | N/A | N/A | N/A | N/A | $- | N/A | N/A | $- | N/A | $- | N/A | N/A | $- | N/A | N/A | $- | N/A | $- | N/A | $- | $- | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | - | - | - | - | - | - | - | - | - | - | - | ||
| Provide additional information or clarification here: | |||||||||||||||||||||||||||||||||||||||||||||
Sheet 10: Other Funding Sources
| [Cooperative Agreement]: Resource Use and Cost Inventory Tool | |||||||||||||||||
| Other Funding Sources | |||||||||||||||||
| Instructions: Recipient, Reporting Period, and Total Costs and Totals in yellow will automatically be populated due to the Excel formula within each cell. For the other funding sources table, it is encouraged that you coordinate with other staff in your organization (e.g., principal investigators) in charge of other heart-disease prevention programs as in-kind funding may overlap with <insert Cooperative Agreement> activities. |
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| Recipient: | - | ||||||||||||||||
| Reporting Period: | - | ||||||||||||||||
| Total Additional Funding: | $0.00 | ||||||||||||||||
| Provide an estimate for the percent of Other Funding Sources associated with each sub-strategy during the reporting period. Note: If the funding sources aligns with multiple sub-strategies, provide the best estimate for each sub-strategy. If the funding sources align with all sub-strategies equally, divide the total amount equally across each sub-strategy. Use 0% for any sub-strategy that is not applicable for the funding source. (Write-In) |
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| List of Other Funding Source(s) (State budget, other CDC program, other Federal program, Other in-kind, Funding for unallowable grant costs, other funding) (Write-In) |
Total Amount ($) (Write-In) |
List Services/ Programs Supported (i.e. YMCA, Million Hearts, etc.) (Write-In) |
1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | ||||
| TOTAL | $- | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | ||||
| Provide additional information or clarification here: | |||||||||||||||||
Sheet 11: Other Costs and Resources
| [Cooperative Agreement]: Resource Use and Cost Inventory Tool | |||||||||||||||||||||||||
| Other Costs and Resources | |||||||||||||||||||||||||
| Instructions: Recipient, Reporting Period and Totals in yellow will automatically be populated due to the Excel formula within each cell. Please fill out the information below by first identifying other costs and resources used for <insert Cooperative Agreement> implementation that have not been categorized or reported in other tabs of this tool. After indentifying the cost or resource, briefly describe the cost/resource, associated dollar amounts, and use columns E-O to select the sub-strategies associated with the reported cost/resource. |
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| Recipient: | - | ||||||||||||||||||||||||
| Reporting Period: | - | ||||||||||||||||||||||||
| Total Other Costs & Resources: | $- | ||||||||||||||||||||||||
| Provide an estimate for the percent of the Other Cost/Resource associated with each sub-strategy during the reporting period. Note: If the Other Cost/Resource aligns with multiple sub-strategies, provide the best estimate for each sub-strategy. If the Other Cost/Resource aligns with all sub-strategies equally, divide the total amount equally across each sub-strategy. Use 0% for any sub-strategy that is not applicable for the Other Cost/Resource. (Write-In) |
Total Equipment/Resource Costs (Annually) per sub-strategy | ||||||||||||||||||||||||
| List of Other Cost/Resource (Write-In) |
Other Cost/Resource Description (Write-in) | Total Amount ($) (Write-In) |
1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | 1A | 1B | 1C | 1D | 2A | 2B | 2C | 3A | 3B | 3C | 3D | |
| TOTAL | N/A | $- | - | - | - | - | - | - | - | - | - | - | - | ||||||||||||
| Provide additional information or clarification here: | |||||||||||||||||||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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