Form CMS-684 A CMS-684 A ESRD Network Business Proposal Forms

J.7	CMS Form 684-A
Page 4		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____
		YEAR 1	7-1-06 to 6-30-07			Appendix A
			No of	Hourly	Number	Total
DIRECT MEDICARE COSTS			FTEs	Rate	of Hours	Salary
a. LABOR
1. Project Director/Executive Director						#VALUE!
2. Quality Improvement Manager						$0
3. RN (w/ Nephrology experience)						$0
4. Office Mgr./Bookkeeper						$0
5. Data/Info Systems Manager						$0
6. Data Entry & Tracking Clerical Support						$0
7. Community Outreach Coordinator - (MSW or eqiv)						$0
8. Admin Assistant/Secretary						$0
9. Clerical Support (non-data clerks, receptionist, etc)						$0
10. Patient Services Coordinator						$0
ADDITIONAL POSITIONS						$0
11.						$0
12.						$0
13.						#VALUE!
14.						$0
TEMP. LABOR						$0
a.						$0
b.						$0
c.						$0
SUBTOTAL - DIRECT LABOR			0.0	#DIV/0!	0	#VALUE!
J.7	CMS Form 684-A
Page 5		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____
		YEAR 2	7-1-07 to 6-30-08			Appendix A
			No of	Hourly	Number	Total
DIRECT MEDICARE COSTS			FTEs	Rate	of Hours	Salary
a. LABOR
1. Project Director/Executive Director						$0
2. Quality Improvement Manager						$0
3. RN (w/ Nephrology experience)						$0
4. Office Mgr./Bookkeeper						$0
5. Data/Info Systems Manager						$0
6. Data Entry & Tracking Clerical Support						$0
7. Community Outreach Coordinator - (MSW or eqiv)						$0
8. Admin Assistant/Secretary						$0
9. Clerical Support (non-data clerks, receptionist, etc)						$0
10. Patient Services Coordinator						$0
ADDITIONAL POSITIONS						$0
11.						$0
12.						$0
13.						#VALUE!
14.						$0
TEMP. LABOR						$0
a.						$0
b.						$0
c.						$0
SUBTOTAL - DIRECT LABOR			0.0	#DIV/0!	0	#VALUE!
J.7	CMS Form 684-A
Page 6		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____
		YEAR 3	7-1-08 to 6-30-09			Appendix A
			No of	Hourly	Number	Total
DIRECT MEDICARE COSTS			FTEs	Rate	of Hours	Salary
a. LABOR
1. Project Director/Executive Director						$0
2. Quality Improvement Manager						$0
3. RN (w/ Nephrology experience)						$0
4. Office Mgr./Bookkeeper						$0
5. Data/Info Systems Manager						$0
6. Data Entry & Tracking Clerical Support						$0
7. Community Outreach Coordinator - (MSW or eqiv)						$0
8. Admin Assistant/Secretary						$0
9. Clerical Support (non-data clerks, receptionist, etc)						$0
10. Patient Services Coordinator						$0
ADDITIONAL POSITIONS						$0
11.						$0
12.						$0
13.						#VALUE!
14.						$0
TEMP. LABOR						$0
a.						$0
b.						$0
c.						$0
SUBTOTAL - DIRECT LABOR			0.0	#DIV/0!	0	#VALUE!
J.7	CMS Form 684-B
Page 7		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____
PROGRAM CONSULTANTS		YEAR 1	7-1-06 to 6-30-07				Appendix B
					Rate	Number	Total
Name			Position		Per Hour	Of Hours	Costs
1.							$0
2.							$0
3.							$0
4.							$0
5.							$0
6.							$0
7.							$0
8.							$0
9.							$0
10.							$0
11.							$0
12.							$0
13.							$0
14.							$0
15.							$0
TOTAL						0	$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).
J.7	CMS Form 684-B
Page 8		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____
PROGRAM CONSULTANTS		YEAR 2	7-1-07 to 6-30-08				Appendix B
					Rate	Number	Total
Name			Position		Per Hour	Of Hours	Costs
1.							$0
2.							$0
3.							$0
4.							$0
5.							$0
6.							$0
7.							$0
8.							$0
9.							$0
10.							$0
11.							$0
12.							$0
13.							$0
14.							$0
15.							$0
TOTAL						0	$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).
J.7	CMS Form 684-B
Page 9		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____
PROGRAM CONSULTANTS		YEAR 3	7-1-08 to 6-30-09				Appendix B
					Rate	Number	Total
Name			Position		Per Hour	Of Hours	Costs
1.							$0
2.							$0
3.							$0
4.							$0
5.							$0
6.							$0
7.							$0
8.							$0
9.							$0
10.							$0
11.							$0
12.							$0
13.							$0
14.							$0
15.							$0
TOTAL						0	$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).
J.7	CMS Form 684-C
Page 10			ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
				NETWORK # ____
OUT OF AREA TRAVEL		YEAR 1	7-1-06 to 6-30-07				Appendix C-1
	NO. Of	NO. Of	DESTINATION			APPROX.
POSITION	ATTENDEES	TRIPS	FROM	TO	PURPOSE	DATE(S)	TOTAL
TOTAL	0	0					$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION.
J.7	CMS Form 684-C
Page 11			ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
				NETWORK # ____
OUT OF AREA TRAVEL		YEAR 2	7-1-07 to 6-30-08				Appendix C-1
	NO. Of	NO. Of	DESTINATION			APPROX.
POSITION	ATTENDEES	TRIPS	FROM	TO	PURPOSE	DATE(S)	TOTAL
TOTAL	0	0					$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION.
J.7	CMS Form 684-C
Page 12			ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
				NETWORK # ____
OUT OF AREA TRAVEL		YEAR 3	7-1-08 to 6-30-09				Appendix C-1
	NO. Of	NO. Of	DESTINATION			APPROX.
POSITION	ATTENDEES	TRIPS	FROM	TO	PURPOSE	DATE(S)	TOTAL
TOTAL	0	0					$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION.
J.7	CMS Form 684-D
Page 13			ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
				NETWORK # ____
AREA TRAVEL		YEAR 1	7-1-06 to 6-30-07				Appendix C-2
	NO. Of	NO. Of	DESTINATION			APPROX.
POSITION	ATTENDEES	TRIPS	FROM	TO	PURPOSE	DATE(S)	TOTAL
TOTAL	0	0					$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION.
J.7	CMS Form 684-D
Page 14			ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
				NETWORK # ____
AREA TRAVEL		YEAR 2	7-1-07 to 6-30-08				Appendix C-2
	NO. Of	NO. Of	DESTINATION			APPROX.
POSITION	ATTENDEES	TRIPS	FROM	TO	PURPOSE	DATE(S)	TOTAL
TOTAL	0	0					$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION.
J.7	CMS Form 684-D
Page 15			ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
				NETWORK # ____
AREA TRAVEL		YEAR 3	7-1-08 to 6-30-09				Appendix C-2
	NO. Of	NO. Of	DESTINATION			APPROX.
POSITION	ATTENDEES	TRIPS	FROM	TO	PURPOSE	DATE(S)	TOTAL
TOTAL	0	0					$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION.
J.7	CMS Form 684-E
Page 16		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____
SUBCONTRACTOR		YEAR 1	7-1-06 to 6-30-07				Appendix D
		SUBCONTRACTOR		TIME FRAME		Number	Total
Name		ACTIVITIES/PURPOSE		FROM	TO	Of Hours	Costs
TOTAL						0	$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).
J.7	CMS Form 684-E
Page 17		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____
SUBCONTRACTOR		YEAR 2	7-1-07 to 6-30-08				Appendix D
		SUBCONTRACTOR		TIME FRAME		Number	Total
Name		ACTIVITIES/PURPOSE		FROM	TO	Of Hours	Costs
TOTAL						0	$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).
J.7	CMS Form 684-E
Page 18		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____
SUBCONTRACTOR		YEAR 3	7-1-08 to 6-30-09				Appendix D
		SUBCONTRACTOR		TIME FRAME		Number	Total
Name		ACTIVITIES/PURPOSE		FROM	TO	Of Hours	Costs
TOTAL						0	$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).
J.7	CMS Form 684-F
Page 19		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____				Appendix E
OTHER DIRECT COSTS			7-1-2006 to 6-30-2009
				YEAR 1	YEAR 2	YEAR 3	3-YEAR
				COSTS	COSTS	COSTS	TOTAL
1. Storage							$0
2. Utilities							$0
3. Maintenance & Repairs							$0
4. Depreciation							$0
5. Data Processing							$0
6. Office Supplies							$0
7. Postage & Express Mail							$0
8. Meetings & Conferences							$0
9. Garage & Parking Spaces							$0
10. Dues & Subscriptions							$0
11. Recruiting							$0
12. Temporary Help							$0
13. Continuing Education							$0
14. Legal Fees							$0
15. Accounting/Auditing Fees							$0
16. Printing & Reproduction							$0
17. Other - Attach Schedule							$0
							$0
TOTAL				$0	$0	$0	$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION FOR EACH LINE ITEM.
J.7	CMS Form 684-G
Page 20		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____
FRINGE BENEFITS			7-1-2006 to 6-30-2009				Appendix F
				YEAR 1	YEAR 2	YEAR 3
				COSTS	COSTS	COSTS	3-YR. TOTAL
1. Employer's FICA Expense							$0
2. Federal Unemployment Tax							$0
3. State Unemployment Insurance							$0
4. Disability Insurance							$0
5. Pension Expense							$0
6. Workers Compensation							$0
7. Group Health Insurance							$0
8. Group Life Insurance							$0
9. Employee Relations & Welfare							$0
10. Leave							$0
11. Other - Attach Schedule							$0
TOTAL				$0	$0	$0	$0
NOTE: SUBMIT SUPPORTING JUSTIFICATION(s) FOR EACH LINE ITEM.
J.7	CMS Form 684-H
Page 21		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____
GENERAL & ADMINISTRATION (G&A)			7-1-2006 to 6-30-2009					Appendix G
			YEAR 1	YEAR 2	YEAR 3	Total
			COSTS	COSTS	COSTS	Costs
1. RENT						$0
2. LEASED EQUIPMENT						$0
3. TELEPHONE EXPENSES						$0
4. INSURANCE						$0
5.						$0
6.						$0
TOTAL			$0	$0	$0	$0
J.7	CMS Form 684
Page 3		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
			NETWORK # ____		ESRD BUSINESS PROPOSAL FORM SUMMARY
DIRECT MEDICARE COSTS				Year 1	Year 2	Year 3	3-Yr. TOTAL
a. LABOR			(See Appendix A)
1. Project Director/Executive Director				#VALUE!	$0	$0	#VALUE!
2. Quality Improvement Manager				$0	$0	$0	$0
3. RN (w/ Nephrology experience)				$0	$0	$0	$0
4. Office Mgr./Bookkeeper				$0	$0	$0	$0
5. Data/Info Systems Manager				$0	$0	$0	$0
6. Data Entry & Tracking Clerical Support				$0	$0	$0	$0
7. Community Outreach Coordinator - (MSW or eqiv)				$0	$0	$0	$0
8. Admin Assistant/Secretary				$0	$0	$0	$0
9. Clerical Support (non-data clerks, receptionist, etc)				$0	$0	$0	$0
10. Patient Services Coordinator				$0	$0	$0	$0
ADDITIONAL POSITIONS				$0	$0	$0	$0
11.				$0	$0	$0	$0
12.				$0	$0	$0	$0
13.				#VALUE!	#VALUE!	#VALUE!	#VALUE!
14.				$0	$0	$0	$0
TEMP. LABOR				$0	$0	$0	$0
a.				$0	$0	$0	$0
b.				$0	$0	$0	$0
c.				$0	$0	$0	$0
	SUBTOTAL - DIRECT LABOR			#VALUE!	#VALUE!	#VALUE!	#VALUE!
b. PROGRAM CONSULTANTS			(See Appendix B)	$0	$0	$0	$0
c. TRAVEL		(See Appendices C-1 & C-2)		$0	$0	$0	$0
d. SUBCONTRACTORS			(See Appendix D)	$0	$0	$0	$0
e. OTHER DIRECT COSTS			(See Appendix E)	$0	$0	$0	$0
f. FRINGE BENEFITS			(See Appendix F)	$0	$0	$0	$0
g. GENERAL & ADMINISTRATIVE			(See Appendix G)	$0	$0	$0	$0
h. TOTAL COSTS (excluding fee)				#VALUE!	#VALUE!	#VALUE!	#VALUE!
i. FEE				$0	$0	$0	$0
j. TOTAL COSTS WITH FEE				#VALUE!	#VALUE!	#VALUE!	#VALUE!