| Form Approved | |||||||||
| OMB No. 0990- | |||||||||
| Exp. Date XX/XX/20XX | |||||||||
| Cost Study of Teen Pregnancy Prevention Programs | |||||||||
| Implementing Agency Cost Survey | |||||||||
| Introduction and Instructions | |||||||||
| Please scroll down to read all instructions. | |||||||||
| The Cost Study of Evidence-Based Teen Pregnancy Prevention Programs aims to expand the available information on teen pregnancy prevention program costs. The Office of Adolescent Health (OAH) within the U.S. Department of Health and Human Services and Mathematica Policy Research are conducting the cost study. The study will examine how much it costs to implement selected evidence-based teen pregnancy prevention programs and the cost-effectiveness of several of these programs. |
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| What is this survey about? | |||||||||
| This survey is for TPP grantee organizations and their selected partner or implementing agencies. It asks questions about the resources required to implement a teen pregnancy prevention program. The survey is designed to gather information on all resources used by the program, including resources that the program does not pay for directly and that may not be reflected in expenditure records (such as the value of volunteer time or donated office space). | |||||||||
| How is the survey organized? | |||||||||
| The survey is divided into nine sections, labeled A through I. Each section asks questions about a specific type of cost or resource and appears as a separate tab in this Excel workbook. You can access each section by clicking on the tabs at the bottom of this page. You should complete the questions in all sections. Please save this file after completing each section. | |||||||||
| What time period is covered? | |||||||||
| Please report costs for [REPORTING PERIOD] when completing the survey. If you do not have information for that period available, please report costs during the most recent [PROGRAM CYCLE/FISCAL YEAR] completed prior to August 2014. The survey refers to the [X]-month time frame you select as the "reporting period". | |||||||||
| What information or records will I need to complete the survey? | |||||||||
| You will need information about agency expenditures and use of resources, such as facilities and equipment. Please use actual expenditure records rather than budgets when gathering information to answer survey questions. Information from budgets does not always represent actual expenditures or resource use. It may be helpful to review the entire survey before starting it to identify the kinds of information that are required. (To print the entire survey, click Print and select the Entire workbook option under Print what.) |
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| Who in my agency should complete the survey? | |||||||||
| A person who is familiar with agency expenditures and accounting records should have primary responsibility for completing the survey. This person may need to consult with other people in the agency to gather information required to address some questions. | |||||||||
| How do I navigate through the survey? | |||||||||
| Each section of the survey appears on a separate tab in this workbook. Click on the tabs below to view and complete each section of the survey. In each section, enter information or select answers in fields with the labels "Click here and start typing" or "Click here and select from list". You can use the tab key or mouse button to move between answer fields. (Areas outside the answer fields are locked to prevent changes.) Please save your work frequently to ensure your answers are recorded. | |||||||||
| What should we do when we have completed the survey? | |||||||||
| Please complete the survey within three weeks after receiving it. When you have completed the survey, please save the file, encrypt it according to the instructions provided, and email it to the address provided. | |||||||||
| How will survey data be used? | |||||||||
| Information gathered through this survey will be secure to the extent permitted by law. Only members of the research team will have access to survey responses. The study team will generate aggregate estimates of the overall program costs to each grantee, the costs of different program activities and components, and costs per program participant. For grantees conducting program impact evaluations, the team will also compare these cost estimates to the measured program impacts on youth outcomes. The aggregate findings will be presented in peer-reviewed journal articles and reports. | |||||||||
| Thank you for your participation in this important study. If you have questions about how to complete the survey, please contact the Mathematica staff member who sent you the survey. If you have questions about the study purpose or methods, please contact Brian Goesling at bgoesling@mathematica-mpr.com. | |||||||||
| This survey was prepared by Mathematica Policy Research with support from the Office of Adolescent Health. Some elements are adapted from: French, Michael T. Drug Abuse Treatment Cost Analysis Program (Program Version). Sixth Edition. Coral Gables, FL: University of Miami, 1998. | |||||||||
| According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 8 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer | |||||||||
| SECTION A: YOUR AGENCY | ||||||||||||
| This section requests basic information about your agency and the time period for cost information you provide. Please review the pre-populated information and complete all blank entries. | ||||||||||||
| 1) | What is the official name of your agency? | |||||||||||
| [Click here and start typing] | ||||||||||||
| 2) | Please provide contact information for the person primarily responsible for completing this survey. | |||||||||||
| Name | [Click here and start typing] | |||||||||||
| Position/Title | [Click here and start typing] | |||||||||||
| [Click here and start typing] | ||||||||||||
| Telephone | [Click here and start typing] | |||||||||||
| Address | [Click here and start typing] | |||||||||||
| 3) | What is the period for which you are reporting costs (the "reporting period")? | |||||||||||
| [Enter month] | [Enter Year] | TO | [Enter Month] | [Enter Year] | ||||||||
| 4) | If any unusual circumstances may have affected costs during the reporting period you indicated (for example, unusually high staff turnover or major changes in agency operations), please use the space below to describe them. | |||||||||||
| [Click here and start typing.] | ||||||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | ||||||||||||
| SECTION B: SALARIES AND FRINGE BENEFITS | |||||||||
| This section asks questions about salary and fringe benefit expenses for teen pregnancy prevention program staff during the [REPORTING PERIOD]. Please scroll down to answer all questions (1-4). | |||||||||
| 1a) | Using the table below, please indicate expenditures for salaries and fringe benefits for staff positions of the teen pregnancy prevention program during the reporting period. Include positions for any staff who spent time on the program. This should include staff involved in program/project management, program delivery and facilitation, communication and outreach, professional development and training, fidelity monitoring, evaluation activities and administrative functions (e.g. accounting, grant management, etc.). For each position: - Indicate the number of full-time equivalents (FTEs). If a staff member worked only part of the reporting period, please adjust the FTE for that position accordingly. For example, a staff member who worked 32 hours per week for 6 months during the reporting year would be 0.4 FTE (0.8 x 0.5). - Enter the average full-time annual salary for the position. - Enter the value of payroll taxes and any fringe benefits paid, either as a percentage of salary or as a dollar amount. - Indicate the percentage of time allocated to the teen pregnancy prevention program. - Select the funding source for the position. - Enter the percentage of the annual salary funded by OAH (if applicable). |
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| Staff Position/Title | Number of FTEs | Average Full-Time Annual Salary | Value of Payroll Taxes and Fringe Benefits (enter as a percentage of salary or as a total dollar amount for the position) |
Percent of Time Allocated to the Teen Pregnancy Prevention Program | Funding Source | Percent of Annual Salary Funded by OAH | |||
| Value as a Percentage of Salary | or | Total Amount | |||||||
| or | [Click here and select from list] | ||||||||
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| or | [Click here and select from list] | ||||||||
| 1b) | What is the annual full-time equivalent (FTE) for staff who worked on the teen pregnancy prevention program? | ||||||||
| [Click here and start typing.] | |||||||||
| 1c) | If there were staff transitions or turnover during the cost reporting period, please describe these in the box below, stating the positions where transitions occurred. | ||||||||
| [Click here and start typing.] | |||||||||
| 2) | Please indicate which payroll taxes and benefits are included in the figures reported in Table 1a. Indicate YES or NO for each type of tax or benefit. | ||||||||
| Social Security (FICA) | [Click here and select from list] | ||||||||
| Unemployment insurance | [Click here and select from list] | ||||||||
| Health insurance | [Click here and select from list] | ||||||||
| Life insurance | [Click here and select from list] | ||||||||
| Pension/retirement | [Click here and select from list] | ||||||||
| Workers compensation | [Click here and select from list] | ||||||||
| Disability | [Click here and select from list] | ||||||||
| Other benefits | [Click here and select from list] | ||||||||
| 3a) | Did your teen pregnancy prevention program incur any costs for overtime during the reporting period? (Please select YES or NO from the drop-down list.) | ||||||||
| [Click here and select from list] | |||||||||
| 3b) | If you answered YES to question 3a, please enter the total cost of overtime during the reporting year. | ||||||||
| [Enter dollar amount here.] | |||||||||
| 4) | Please use the space below to enter any explanatory notes for the information provided in this section. | ||||||||
| [Click here and start typing.] | |||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | |||||||||
| SECTION C: DONATED LABOR | ||||||||
| This section asks about the value of any labor donated to the teen pregnancy prevention program (volunteers) during the [REPORTING PERIOD]. Please scroll down to answer all questions (1-3). | ||||||||
| 1) | Did your agency's teen pregnancy prevention program benefit from any donated labor/volunteers during the reporting period? Please select YES or NO from the drop-down list. | |||||||
| [Click here and select from list] | ||||||||
| 2a) | If you answered YES to question 1, please use the table below to estimate the value of donated labor. For each volunteer, please enter the: - position or job description - number of hours worked per month - number of months worked during the year - estimated hourly wage for a paid employee in that position |
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| Position or Job Description | Number of Hours Worked Per Month | Number of Months Worked Per Year | Estimated Hourly Wage for Paid Employee (Dollars) | |||||
| 2b) | Please describe the source of your estimates for hourly wages. | |||||||
| [Click here and start typing.] | ||||||||
| 3) | Please use the space below to enter any explanatory notes on the information provided in this section. | |||||||
| [Click here and start typing.] | ||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | ||||||||
| SECTION D: SUPPLIES AND MATERIALS | ||||||||||
| This section asks questions about the cost or value of supplies and materials used by the teen pregnancy prevention program during the [REPORTING PERIOD]. Please scroll down to answer all questions (1-2). | ||||||||||
| 1) | Using the table below, please indicate the cost or estimated value of all supplies and materials used by the teen pregnancy prevention program during the reporting period. If your agency received any supplies and materials free of charge, estimate what your agency would have paid to purchase them. For the purposes of this survey, supplies and materials are items used and replenished regularly, not capital assets such as computers. Examples of supplies and materials include program and educational materials, office supplies, and transportation/fuel for program participants. | |||||||||
| Type of Supply or Material | Cost or Estimated Value (Dollars) | Funding or Contribution Source | ||||||||
| [Click here and select from list] | ||||||||||
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| 2) | Please use the space below for any explanatory notes on the information provided in this section. | |||||||||
| [Click here and start typing.] | ||||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | ||||||||||
| SECTION E: EQUIPMENT/CAPITAL ASSETS AND DEPRECIATION | ||||||||||||
| This section asks questions about durable equipment and/or capital assets used by the teen pregnancy prevention program during the [REPORTING PERIOD]. Please scroll down to answer all questions (1-4). | ||||||||||||
| 1) | Please use the table below to itemize any durable equipment or capital asset used by the teen pregnancy prevention program during the reporting period. For the purposes of this survey, durable equipment and capital assets are items with an expected useful life of more than 1 year. Examples include computer systems, automobiles, office furniture, etc. Please indicate: - Type of equipment/asset - Year purchased or received (if information is available) - Original purchase price or estimated value for any equipment the program received and used free of charge (dollars) - Expected useful life (number of years) - Funding or contribution source for each equipment/asset |
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| Type of equipment or asset | Year Purchased or Received | Original Purchase Price or Estimated Value (Dollars) | Expected Useful Life (Number of Years) |
Funding or Contribution Source | ||||||||
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| 2a) | Was any equipment leased or rented by the teen pregnancy prevention program during the reporting period? Please use the drop-down list to select YES or NO. | |||||||||||
| [Click here and select from list] | ||||||||||||
| 2b) | If you answered YES to question 2a, please use the table below to enter the type of equipment leased or rented and the total amount paid during the reporting period. | |||||||||||
| Type of equipment leased or rented | Amount Paid During the Reporting Period (Dollars) | Source of Funding or Contribution | ||||||||||
| [Click here and select from list] | ||||||||||||
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| 3a) | Did your teen pregnancy prevention program calculate a total depreciation cost for the reporting period? Please use the drop-down list to select YES or NO. | |||||||||||
| [Click here and select from list] | ||||||||||||
| 3b) | If you answered YES to question 3a, please enter the total depreciation cost in the space below. | |||||||||||
| Total depreciation cost during the reporting period: | ||||||||||||
| 4) | Please use the space below to provide information on calculations and data sources or other explanatory notes for this section. If reporting depreciation cost, please describe which equipment is accounted for in the depreciation cost. | |||||||||||
| [Click here and start typing.] | ||||||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | ||||||||||||
| SECTION F: CONTRACTED SERVICES | |||||||||||||
| This section asks questions about the value of contracted services (for example, repair or maintenance services or technical consultants) that your program purchased during the [REPORTING PERIOD]. Please scroll down to answer all questions (1-3). | |||||||||||||
| 1a) | Did your agency contract with a company or organization to provide services for the teen pregnancy prevention program during the reporting period? Please use the drop-down box to select YES or NO. | ||||||||||||
| [Click here and select from list] | |||||||||||||
| 1b) | If you answered YES to question 1a, please use the table below to enter information on the contracted services purchased and their cost during the reporting period. If you only have a total value for contracted services, leave the table blank and enter the total amount in the appropriate space below. | ||||||||||||
| Name of Contractor or Service Provider | Type of Contracted Service | Cost Incurred During Reporting Period (Dollars) | Funding Source | ||||||||||
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| Total expenses for contracted services during the reporting period, in dollars (if services are not itemized above): | |||||||||||||
| 2a) | Did your teen pregnancy prevention program contract with a professional or technical consultant during the reporting period? Please use the drop-down list to select YES or NO. | ||||||||||||
| [Click here and select from list] | |||||||||||||
| 2b) | If you answered YES to question 2a, please use the table below to list consultants with whom the program contracted and the amount paid during the reporting period. Do not include costs reported in question F.1. If you only have a total for consulting services, leave the table blank and enter the total amount in the appropriate space below. | ||||||||||||
| Name of Consultant | Type of Service Provided | Cost Incurred During Reporting Period (Dollars) | Funding Source | ||||||||||
| [Click here and select from list] | |||||||||||||
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| Total expenses for consulting services during the reporting period, in dollars (if services are not itemized above): | |||||||||||||
| 3) | Please use the space below to provide information on calculations and data sources or other explanatory notes for this section. | ||||||||||||
| [Click here and start typing.] | |||||||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | |||||||||||||
| SECTION G: BUILDINGS AND FACILITIES | ||||||||||||
| This section asks questions about cost of office space or other facilities used by your teen pregnancy prevention program during the [REPORTING PERIOD]. Please scroll down to answer all questions (1-2). | ||||||||||||
| 1) | Please use the table below to list all buildings or other facilities regularly used by your teen pregnancy prevention program during the reporting period, including office space and offsite facilities. Include all facilities the teen pregnancy prevention program used free of charge or for below market rates. For each building or facility, please indicate: - Building or facility name - Type of building or facility (office, hospital, school, etc.) - Approximate size of space used by the teen pregnancy prevention program (in square feet) - Approximate percentage of total building or facility space used by the teen pregnancy prevention program - Length of time the space is used by the teen pregnancy prevention program during the reporting period - Total amount paid or estimated cost during the reporting period - Use the drop-down list to indicate whether the payments reported are for the entire building or only the portion of the building used by the teen pregnancy prevention program. - Use the drop-down lists to indicate whether the payments represent the fair market value of the building or facility space, that is whether the space is leased or rented at or below market rates. -Use the drop-down lists to indicate which funding source covered the facilities costs. If you cannot estimate the annual cost of leasing or renting the space in each building or facility based on fair market value, the research team will use information on average local rental rates to create one. |
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| Building or Facility Name | Type of Building or Facility | Approximate Size of Space Used by Teen Pregnancy Prevention Program (square feet) | Approximate Percentage of Total Building Space Used by Teen Pregnancy Prevention Program | Length of Time Space Is Used by Teen Pregnancy Prevention Program | Amount Paid to Use Building During the Reporting Year (Dollars) | Does Amount Paid Represent Total Building Cost or Teen Pregnancy Prevention Program Portion? | Does Amount Paid Represent Fair Market Value? | Funding or Contribution Source | ||||
| Building 1 | [Click here and select from list] | [Click here and select from list] | [Click here and select from list] | |||||||||
| Building 2 | [Click here and select from list] | [Click here and select from list] | [Click here and select from list] | |||||||||
| Building 3 | [Click here and select from list] | [Click here and select from list] | [Click here and select from list] | |||||||||
| Building 4 | [Click here and select from list] | [Click here and select from list] | [Click here and select from list] | |||||||||
| Building 5 | [Click here and select from list] | [Click here and select from list] | [Click here and select from list] | |||||||||
| Building 6 | [Click here and select from list] | [Click here and select from list] | [Click here and select from list] | |||||||||
| 2) | Please use the space below to provide information on calculations and data sources or other explanatory notes for this section. | |||||||||||
| [Click here and start typing.] | ||||||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | ||||||||||||
| SECTION H: MISCELLANEOUS/OTHER RESOURCES | ||||||||||
| This section is for recording any expenditures not reported already in other tabs. You should list any outstanding items or services used by your teen pregnancy prevention program during the [REPORTING PERIOD]. Please scroll down to answer all questions (1-2). | ||||||||||
| 1) | Using the table below, please enter the cost or estimated value of all miscellaneous items and services purchased or received by the teen pregnancy prevention program during the reporting period and not reported elsewhere in the survey. If your agency received any miscellaneous items free of charge, estimate what your agency would have paid to purchase them. Examples of miscellaneous items include fees paid to developers, travel costs related to program delivery (transportation/mileage), travel costs not related to program delivery (e.g., costs associated with professional development, training, conferences), incentives, building utilities, etc. | |||||||||
| Type of Item or Service Purchased for the Teen Pregnancy Prevention Program | Cost or Estimated Value (Dollars) | Funding or Contribution Source | ||||||||
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| 2) | Please use the space below to provide details on calculations and data sources or other explanatory notes for this section. | |||||||||
| [Click here and begin typing.] | ||||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | ||||||||||
| SECTION I: INDIRECT COSTS | |||||||||||
| This section asks questions about indirect costs during the [REPORTING PERIOD]. Indirect costs (sometimes called "overhead") are costs for shared agency functions, such as accounting, human resources, and marketing. These functions may benefit multiple programs or departments. Costs for these shared functions are often allocated through an indirect cost rate or a total charge for indirect expenses. Agencies differ in the way that they calculate and allocate indirect costs. Please scroll down to answer all questions (1-7). |
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| 1) | Does your agency calculate indirect costs for the teen pregnancy prevention program using an established indirect cost rate (for example, a federally negotiated indirect cost rate)? Please select YES or NO from the drop-down list. | ||||||||||
| [Click here and select from list] | |||||||||||
| 2a) | If you answered YES to question 1, please enter the established indirect cost rate your agency used during the reporting period. | ||||||||||
| Agency indirect cost rate (percentage): | |||||||||||
| 2b) | To what expenses is the established indirect cost rate applied? Please use the drop-down list to select an answer (SALARIES ONLY, SALARIES AND FRINGE BENEFITS, or SALARIES AND FRINGE BENEFITS AND OTHER DIRECT COSTS). | ||||||||||
| [Click here and select from list] | |||||||||||
| 3a) | Does your agency calculate indirect costs for the teen pregnancy prevention program without using an established indirect cost rate? Please select YES or NO from the drop-down list. | ||||||||||
| [Click here and select from list] | |||||||||||
| 3b) | If your agency calculates indirect costs for the teen pregnancy prevention program but does not use an established indirect cost rate, please describe the method your agency uses below. Please also provide an estimated total for indirect costs during the reporting period. | ||||||||||
| Method for calculating indirect costs: | |||||||||||
| [Click here and start typing.] | |||||||||||
| 4) | If your agency calculated total indirect costs for the teen pregnancy prevention program during the reporting period, please enter that amount below. | ||||||||||
| Total calculated indirect costs for the teen pregnancy prevention program during the reporting period (dollar amount): | |||||||||||
| 5) | Do any indirect costs charged to the teen pregnancy prevention program cover costs you have reported in other sections of this survey? Please use the drop-down list to answer YES, NO, or NOT APPLICABLE. | ||||||||||
| [Click here and select from list] | |||||||||||
| 6) | Please itemize below the resources covered under indirect costs charged to the teen pregnancy prevention program (e.g., accounting functions, building maintenance) , including any resources reported in other sections of the survey. | ||||||||||
| [Click here and start typing.] | |||||||||||
| 7) | Please use the space below to enter any explanatory notes on the information provided in this section. | ||||||||||
| [Click here and start typing.] | |||||||||||
| END OF SURVEY. THANK YOU FOR YOUR PARTICIPATION. | |||||||||||
| PLEASE SAVE THIS FILE AND RETURN IT TO THE EMAIL ADDRESS PROVIDED. | |||||||||||
| [Click here and select from list] |
| YES |
| NO |
| Q.I2b |
| [Click here and select from list] |
| SALARIES ONLY |
| SALARIES AND FRINGE BENEFITS |
| SALARIES AND FRINGE BENEFITS AND OTHER DIRECT COSTS |
| Q.I4 |
| [Click here and select from list] |
| YES |
| NO |
| NOT APPLICABLE |
| Q.G2a |
| [Click here and select from list] |
| TOTAL COST |
| TPP PROGRAM PORTION |
| WhoPaysSalary (Worksheet B) |
| [Click here and select from list] |
| ONLY OAH FUNDING |
| ONLY OTHER FUNDING |
| OAH AND OTHER FUNDING COMBINED |
| WhoPays (Worksheets D, E, G, H) |
| [Click here and select from list] |
| OAH FUNDING |
| OTHER FUNDING |
| IN-KIND CONTRIBUTIONS FROM THE AGENCY |
| IN-KIND CONTRIBUTIONS FROM OUTSIDE THE AGENCY |
| WhoPaysContracts (Worksheet F) |
| [Click here and select from list] |
| ONLY OAH FUNDING |
| ONLY OTHER FUNDING |
| OAH AND OTHER FUNDING COMBINED |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |