Form 1 Attachment 1_Cost Tool_FINAL

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Overview

Instructions
Salary and Personnel
Overhead and Infrastructure
Contracted Services
Model Cost, Tools & Curricula
Training
Consumable Supplies
Non-Consumable Supplies
Travel
Questionnaire

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Sheet 1: Instructions

Instructions

Thank you for completing the Home Visiting Program Cost Reporting Tool. Please go through all of the tabs at the bottom of the excel workbook and provide the requested information. For all requested cost information please provide your actual expenses in the previous fiscal year. The tool includes help popups throughout to provide additional information about how to complete each section. Please contact your technical assistance liaison if you have any questions about the information needed in each section.

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Sheet 2: Salary and Personnel

Salary and Personnel
	In this section, please list the job title and annual salary (including benefits) for all staff members in your organization. Report whether each staff member was fully or partially funded out of MIECHV funds and if partially funded, by approximately what percentage. For each staff member please also provide the approximate amount of time spent on each of the staff activity categories. Many staff may spend time on just one activity, but for staff that spend time on multiple activities (e.g. service delivery and outreach) list the approximate percentage of time spent on each activity. The total percentage of time spent on all activities should add to 100%. You can click on each activity for a description of what falls into that category.
		Number of Staff	Annual Salary (including benefits)	Is this position MIECHV funded?	Percent MIECHV Funded (if partial)	Staff Activity Categories
	Job Title					Service Delivery	Outreach	Program Management/ Coordination	Supervising	Admin/Data entry	Executive	Other	Total Allocation (Do not enter data)
						% Time Allocations
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Sheet 3: Overhead and Infrastructure

Overhead and Infrastructure

In this section, please provide information about your organization's overhead and infrastructure costs in the previous fiscal year. Organizations charge for some overhead and infrastructure costs differently, so use the method that is most appropriate for your organization. If your organization has an indirect rate that covers general overhead expenses, include total annual costs for those expenses in the overhead costs portion. If your organization tracks infrastructure expenses such as rent, utilities, and maintenance separately from indirect costs, list those expenses in the infrastructure section. For all expenses, please also report whether it was fully or partially funded out of MIECHV funds and if partially funded, by approximately what percentage. You can click on each cost category for a description of what falls into that category.

Annual Expenditures

Is this expense MIECHV funded?

Percent MIECHV Funded (if partial)

Overhead Costs

Institutional Indirect Costs

Unallowable Indirect Costs

Infrastructure Expenses

Office Rent

Utilities and Maintenance

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Sheet 4: Contracted Services

Contracted Services

In this section, please provide information about your organization's expenses on contracted services in the previous fiscal year. Please enter the total expenditure for each of the contracted service categories below. For all expenses, please also report whether it was fully or partially funded out of MIECHV funds and if partially funded, by approximately what percentage. You can click on each contracted services category for a description of what falls into that category.

Annual Expenditures

Is this expense MIECHV funded?

Percent MIECHV Funded (if partial)

Contracted Services

Screening Services

Data Services

Outreach Services

Service Delivery

Model Consultation

Other Consultation

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Sheet 5: Model Cost, Tools & Curricula

Model Costs, Tools, and Curricula

In this section, please enter data on fees that your organization paid to the home visiting model developer and expenses related to assessment, tools and curricula in the previous fiscal year. Model fees include the startup fee and annual ongoing fees. Additional fees not covered in the overall fee such as additional consultation fees or training tuition should be listed in the consultant services and training sections. For all expenses, please also report whether it was fully or partially funded out of MIECHV funds and if partially funded, by approximately what percentage. You can click on each category for a description of what falls into that category.

Annual Expenditures

Is this expense MIECHV funded?

Percent MIECHV Funded (if partial)

Model Fees

Startup Model Fee

Annual Model Fee

Assessment, Tools, and Curricula

Startup Model Curricula Fees

Annual Model Curricula Fees

Additional curricula fees

Developmental screening, assessment, and outcome measurement tools

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Sheet 6: Training

Training

In this section, please provide information about your organization's expenses on training in the previous fiscal year. Please enter the total expenditure for each of the training categories below. For all expenses, please also report whether it was fully or partially funded out of MIECHV funds and if partially funded, by approximately what percentage. You can click on each training category for a description of what falls into that category.

Annual Expenditures

Is this expense MIECHV funded?

Percent MIECHV Funded (if partial)

Training

Professional Development

Staff Replacement

Home visitor initial training tuition

Supervisor initial training tuition

Administration orientation tuition

Other training tuition

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Sheet 7: Consumable Supplies

Consumable Supplies

In this section, please provide information about your organization's expenses on consumable supplies in the previous fiscal year. Please enter the total expenditure for each of the supply categories below. For all expenses, please also report whether it was fully or partially funded out of MIECHV funds and if partially funded, by approximately what percentage. You can click on each supply category for a description of what falls into that category.

Annual Expenditures

Is this expense MIECHV funded?

Percent MIECHV Funded (if partial)

Administrative Supplies

Startup supply costs

Consumable administrative supplies

Service Delivery Materials

Client support materials

Consumable programmatic materials

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Sheet 8: Non-Consumable Supplies

Non-consumable Supplies

In this section, please provide information about your organization's expenses on non-consumable supplies. Organizations may not make purchases of specific non-consumable supplies every year, so we ask you to report the purchase price and typical years of use and will automatically use these values to compute the annualized value of the supplies. Non-consumable supplies include computers and other electronics equipment, computer software, phones, automobiles, etc. This also includes the maintenance costs associated with any vehicles. For all supplies, please also report whether it was fully or partially funded out of MIECHV funds and if partially funded, by approximately what percentage.

Non-consumable equipment or supplies

Purchase Price

Expected years of use

Is this expense MIECHV funded?

Percent MIECHV Funded (if partial)

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Sheet 9: Travel

Travel

In this section, please provide information about your organization's expenses on travel in the previous fiscal year. Please enter the total expenditure for each of the travel categories below. For all expenses, please also report whether it was fully or partially funded out of MIECHV funds and if partially funded, by approximately what percentage. You can click on each travel category for a description of what falls into that category.

Annual Expenditures

Is this expense MIECHV funded?

Percent MIECHV funded (if partial)

Travel

Mileage to families for service delivery

Mileage for outreach

Travel to trainings and meetings

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Sheet 10: Questionnaire

	Questionnaire
	In this section, please answer these questions about your organization's services.
	Questionnaire	Answers	Column1
	For how many years has your agency been implementing each model (list each model implemented by your organization)?
	Please list below all of the funding sources for your agency and the approximate percentage funding from each source.
		Funding Source	Funding Percentage
	Does your agency provide other services as well or share facilities with an agency that provides other services?
	If yes, approximately what percentage of budget does your agency spend providing the services for this model?
	Does your agency receive outreach services from another organization free of charge?
	In the past fiscal year, what percentage of your agency’s home visits took place in rural areas?
	In the past fiscal year, what percentage of your agency’s home visits took place in frontier areas?
	In the past fiscal year, what percentage of your agency’s home visits were successfully completed (i.e. services were provided to the family)?
	In the past fiscal year, what percentage of the families that you served required services in a language other than English?
	In the past fiscal year, what percentage of the families that you served were below 200% of the federal poverty line?
	In the past fiscal year, what percentage of the families that you served were below 100% of the federal poverty line?
	In the past fiscal year, what percentage of the families that you served were below 50% of the federal poverty line?
	In the past fiscal year, what was your average monthly caseload?
	In the past fiscal year, how many visits did a family receive each month on average?
	How many home visitors usually attend each visit with a family?