Form 2 Colorectal Cancer Control Program Cost Assessment Tool--

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Overview

Title Sheet
1. Program Details
2. Funding
3. In-kind
4. Personnel
5. Activities
6. Consultant
7A. Screening
7B. Screening In-Kind
7C. # People Screened
8. Materials & Contracts
9. Administrative
10. Summary
11. Confirmation
Drop-down categories

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Sheet 1: Title Sheet

			ATTACHMENT 5a. Cost Assessment Tool
								Form Approved
								OMB 0920-0745
								Expiration Date: xx/xx/xxxx
				Colorectal Cancer Control Program
				Annual Cost Assessment Tool
				Authors:
				Sujha Subramanian, PhD, Project Director
				Florence Tangka, PhD, Technical Monitor
				Sonja Hoover, MPP
				RTI International
				CDC Contract No. 200-2008-27958 Task 1
				March 2010
Public reporting burden of this collection of information is estimated to average 22 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-24, Atlanta, GA 30333.

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Sheet 2: 1. Program Details

1. PROGRAM DETAILS
	1A. Name			To be populated with site name in Web-CAT
	1B. Address
	1C. Primary contact person
		Name
	Telephone
	Email

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Sheet 3: 2. Funding

2. TOTAL EXPENDITURE
2A. CRCCP Funds
Type of CRCCP funds	$Amount	Comments
Total CRCCP funding for current year*
Unobligated CRCCP funds carried forward from previous year
Amount of CRCCP funds unspent for the current year
Total CRCCP funds expended:	-
2B. Other Funds
Source of other funds	$ Amount	Activity (if applicable)	Comments
(e.g.) CDC Comprehensive Cancer Control Program (CCCP) Funds
(e.g.) State funds
Total funds expended: $	-
Total expenditure $	#REF!
NOTES:
* CRCCP funds are defined as those funds that were awarded directly through the program in the program announcement.

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Sheet 4: 3. In-kind

3. IN-KIND CONTRIBUTION (Excluding for clinical services to patients: i.e. screening and diagnostic tests etc.)
3A. In-Kind Contributions--Labor
Source of in-kind contributions*	Hours contributed	$ Amount	CRCCP Activity (if applicable)	Method used to estimate $ value	Other Methods Explanation/Comments
Nurse	25	$3,000	Providing screening and diagnostic services	Percentage of staff salary
Physician - Scientific Advisory Board	6	$900	Quality Assurance	Other	Estimate (based on hourly rate of $150)
Total:		-
3B. In-Kind Contributions--Non Labor (eg. materials, equipment etc.)
Source of in-kind contributions		$ Amount	CRCCP Activity (if applicable)	Method used to estimate $ value	Other Methods Explanation/Comments
Computer and other electronics		$1,500		Market Price
Total:		-
Total in-kind contributions $		-

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Sheet 5: 4. Personnel

4. PERSONNEL EXPENDITURE
									% Salary Paid by Sources:
	Job Title	FTE % (a full-time employee is 100%)	Total hours per week	Months Employed in Fiscal Year	Salary ( based on annual time worked on all activities)				% Salary paid by CRCCP	% Salary paid by CDC CCCP	% Salary paid by the state	% Salary paid by other source		Comments
					Base	Fringe	Total
ex 1	Project Manager	100%	38	12	40,000	15,000	55,000		50%		50%
ex 2	Data Manager	50%	19	8	15,000	5,000	20,000		100%
1							-
2							-
3							-
4							-
5							-
6							-
7							-
8							-
9							-
10							-
11							-
12							-
13							-
14							-
15							-
												Total staff cost:

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Sheet 6: 5. Activities

5. PERSONNEL ACTIVITIES
Please indicate proportion of time spent on all CRCCP activities regardless of funding source. Refer to Appendix A of user's guide for description of activities.
		(e.g.) Project Manager	(e.g.) Data Manager	0	0	0	0	0	0	0
Program Management		50%
Screening Promotion Activities
- client reminders
- small media
- provider assessment and feedback
- provider reminders
- reduction in structural barriers
- patient navigation and support
- reduction in out-of-pocket costs
- enrolling in insurance programs
- other screening promotion activities
Screening Provision Activities
- establishing provider contracts and billing systems
- providing screening and diagnostic services
- ensuring appropriate treatment for complications and cancers
Quality Assurance and Professional Development
Partnership Development and Maintenance		50%
Clinical and Cost Data Collection and Tracking			85%
Program Monitoring and Evaluation			15%
Other Activities
		100%	100%	0%	0%	0%	0%	0%	0%	0%

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Sheet 7: 6. Consultant

6. CONSULTANT EXPENDITURE
	Job Title	Annual Payment	Activity 1	% Time Activity 1	Activity 2	% Time Activity 2	Activity 3	% Time Activity 3	Total Percent Time
ex 1	Public Relations	$30,000	Small media	100%
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 cost of consultants:	-

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Sheet 8: 7A. Screening

7. SCREENING AND DIAGNOSIS COSTS
	Cost of Screening and Diagnostic Tests
			$ Amount
			FOBT	FIT	Sigmoidoscopy	Colonoscopy	DCBE	CT colonography	Other: Specifiy
	Pre-screening exams
	Electrocardiogram (EKG)
	Blood work
	Office visit fee
	Other
	Bowel preparation
	Screening tests
	Take-home fecal occult blood test (FOBT)
	Take-home fecal immunochemical test (FIT)
	Sigmoidoscopy
	Colonoscopy
	Double-contrast barium enema (DCBE)
	CT colonography (Virtual colonoscopy)
	Anesthesia fee
	Facility fees
	Other
	Diagnostic follow-up tests
	Bowel preparation
	Colonoscopy with biopsy
	Colonoscopy without biopsy
	Double-contrast barium enema (DCBE)
	Pathology fees
	Anesthesia fee
	Facility fees
	Other
	Total cost of screening and follow-up
	Cost of Surveillance Colonoscopy

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Sheet 9: 7B. Screening In-Kind

7B. SCREENING AND DIAGNOSIS IN-KIND COSTS
	In-Kind Contribution of Screening and Diagnostic Tests
			$ Amount (In-Kind Contribution)
			FOBT	FIT	Sigmoidoscopy	Colonoscopy	DCBE	CT colonography	Other: Specifiy
	Pre-screening exams
	Electrocardiogram (EKG)
	Blood work
	Office visit fee
	Other
	Bowel preparation
	Screening tests
	Take-home fecal occult blood test (FOBT)
	Take-home fecal immunochemical test (FIT)
	Sigmoidoscopy
	Colonoscopy
	Double-contrast barium enema (DCBE)
	CT colonography (Virtual colonoscopy)
	Anesthesia fee
	Facility fees
	Other
	Diagnostic follow-up tests
	Bowel preparation
	Colonoscopy with biopsy
	Colonoscopy without biopsy
	Double-contrast barium enema (DCBE)
	Pathology fees
	Anesthesia fee
	Facility fees
	Other
	Total cost of screening and follow-up
	Cost of Surveillance Colonoscopy

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Sheet 10: 7C. # People Screened

7C. NUMBER OF PEOPLE SCREENED AND NUMBER OF PEOPLE ENROLLED IN INSURANCE PROGRAMS
	Number of Individuals Screened (All funding sources: CRCCP and other funds)
		FOBT	FIT	Sigmoidoscopy	Colonoscopy	DCBE	CT colonography	Other: Specify	Total
	Total number of individuals screened								0
	Total number of screening tests performed								0
	Total number of follow-up colonoscopies								0
	Total number of adenomatous polyps/lesions detected								0
	Total number of cancers detected								0
	Total	0	0	0	0	0	0	0	0
	Total Number of Individuals Undergoing Surveillance
	Total Number of Individuals Enrolled in Insurance Programs

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Sheet 11: 8. Materials & Contracts

8. CONTRACTS, TRAVEL, MATERIALS OR SERVICES PURCHASED (Excluding clinical services)
	Type of Service Purchased	CRCCP Activity	Amount ($)	Cost Calculation	Funding Source
ex 1	Sub-award to local health department	Client reminders	$10,000	Actual	Other
ex 2	Travel for Reverse Site Visit	Program Management	$5,000	Actual	CRCCP
	Total cost of contracts, travel, materials and supplies		-

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Sheet 12: 9. Administrative

9. ADMINISTRATIVE COSTS
9A. Allocation Methodology		Y/N		$ Amount
Proportion of direct cost				0
Please indicate percent of direct cost used			%
Lump-sum payment				0
Other: specify _______________________				0
9B. Types of costs included in the administrative or overhead costs reported above:		Y/N		$ Amount
Rent for office space			if no, provide amount
(including water, gas, electric, etc)
Repairs/maintenance			if no, provide amount
Network connection/maintenance			if no, provide amount
(i.e. internet connection charge)
Phone Service			if no, provide amount
(i.e. local phone service, long distance or cell phone charges)
Shared office equipment			if no, provide amount
Other costs:
Specify:			provide amount
Total administrative/indirect cost				0

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Sheet 13: 10. Summary

10. SUMMARY OF DATA
Cost by Budget Categories		Amount ($)	Percent of Total (%)
Labor			#DIV/0!
Consultants		0	#DIV/0!
Screening, Diagnosis and Surveillance			#VALUE!
Materials & Contracts		0	#DIV/0!
Administrative			#DIV/0!
Total Cost Allocated to Program Activities		0
Total Expenditures		0
Total Cost Allocated to Program Activities		0
Difference		0
In-kind Contributions		0
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Excel Report

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Sheet 14: 11. Confirmation

Please verify that all relevant fields have been completed on all 12 CAT screens. Once completed, please confirm that your cost data is ready for use by CDC by clicking below.

Confirm Cost Data Complete

Date last confirmed:

1/2/2009 2:20PM

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Sheet 15: Drop-down categories

Drop Down Box Categories

Program activities:

Program Management

Screening Promotion Activities

 - client reminders

 - small media

 - provider assessment and feedback

 - provider reminders

 - reduction in structural barriers

 - patient navigation and support

 - reduction in out-of-pocket costs

 - enrolling in insurance programs

- other screening promotion activities

Screening Provision Activities

 - establishing provider contracts and billing systems

 - providing screening and diagnostic services

 - ensuring appropriate treatment for complications and cancers

Quality Assurance and Professional Development

Partnership Development and Maintenance

Clinical and Cost Data Collection and Tracking

Program Monitoring and Evaluation

Other Activities

Source of Non-Federal Funds:

American Cancer Society (ACS)

State funds

In-Kind--Labor:

IT Support

MAB

Provider Services

In-Kind-- Non Labor:

Computer and Other Electronics

Furniture

Office Supplies

Value Estimation Method for In-Kind Contribution:

Market Price

Percentage of Staff Salary

Other

Job Titles:

Senior Manager

Executive Director

Project Director

Chief Medical Officer

Epidemiologist

Data Manager

Health Educator

Patient Navigator

Project Nurse

Sr. Administrative Assistant

Administrative Assistant

Project Coordinator

IT Specialist

Fiscal Assistant

Accountant

Health Surveillance Specialist

Practice Manager

Case Manager

Clinic Manager

Social Worker

Graduate Intern

Family and General Practitioner

Internist (Gastroenterologist)

Surgeon

Nurse

Consultants:

Outreach Specialist

Public Health Nurse

Social Worker

Co-ordinator

Media/marketing Specialist

Info Tech Specialist

Local Colorectal Cancer Control Programs

Alabama

Alaska Native Tribal Health Consortium (Tribal Organization in Alaska)

Arizona

Arctic Slope Native Association (Tribal Organization in Alaska)

California

Colorado

Connecticut

Delaware

Florida

Iowa

Maine

Maryland

Massachusetts

Minnesota

Montana

Nebraska

New Hampshire

New Mexico

New York

Oregon

Pennsylvania

South Dakota

South Puget Intertribal Planning Agency (Tribal Organization in Washington)

Southcentral Foundation (Tribal Organization in Alaska)

Utah

Washington

dichotomous responses

yes

no

Funding Source

CRCCP

State

Other

Numerals

I

II

III

IV

V

VI

VII

VIII

IX

X

XI

XII

XIII

XIV

XV

XVI

XVII

XVIII

XIX

XX

Type of Staff or Volunteer

CRCCP Funded

Provider

MAB

Other

Cost Calculation

Actual

Estimate