Form 1 HVBAT_FINAL_Revised 03.05.2020.xlsx

Maternal, Infant, and Early Childhood Home Visiting Program: Cost Reporting Tool for Pilot Test in Select Local Implementing Agencies

HVBAT_FINAL_Revised 03.05.2020.xlsx

Home Visiting Budget Assistance Tool

OMB: 0906-0025

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0906-0025 can be found here:

2023-03-02 - Revision of a currently approved collection

Document [xlsx]

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Overview

Title
Introduction
1_LIA_Characteristics
2_Labor Costs
3_Overhead and Infrastructure
4_Contracted Services
5_Model Cost, Tools, Curricula
6_Training
7_Consumable Supplies
8_NonConsumable Supplies
9_Travel
Summary
Help
Help_overhead

Sheet 1: Title




Welcome to the
Home Visiting Budget Assistance Tool (HV-BAT)

Version Date: March 14, 2018

Prepared by RTI International and James Bell Associates for:

Health Resources and Services Administration
Maternal and Child Health Bureau
Division of Home Visiting and Early Childhood Systems
5600 Fisher Lane
Rockville, MD 20857

Developed under contract number HHSH250201400038i.


Public Burden Statement: The Home Visiting Budget Assistance tool (HV-BAT) is a reporting tool to collect information on standardized cost metrics from programs that deliver home visiting services. The information requested by this tool will be used to assist Maternal, Infant, and Early Childhood (MIECHV) Program awardees in having the cost information they need to support program planning, sub-recipient monitoring, and research and evaluation activities. 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. The OMB control number for this information collection is 0906-0025 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (Social Security Act, Title V, § 511 (42 U.S.C. § 711(c))). Public reporting burden for this collection of information is estimated to average 18 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

Sheet 2: Introduction

Home Visiting Budget Assistance Tool (HV-BAT)
The Home Visiting Budget Assistance Tool (HV-BAT) was designed to collect costs that local implementing agencies (LIAs) incur when implementing a home visiting model during a 12-month period.
The reported costs should include all resources used for the home visiting model regardless of funding source.

Data Entry Worksheets
Please go through each of the nine data entry worksheets listed below by clicking on the tab name at the bottom of the screen and following the instructions on each tab. Gray cells contain instructions and information pulled from other worksheets, such as model name and reporting period. Users should not enter data in any gray cells.
(1) LIA Characteristics: Collects information on the characteristics of the LIA completing the HV-BAT
(2) Labor Costs: Collects information on the number of staff working on the home visiting model, their salaries, and the percentage time allocations across program activities (please see definitions for each program activity below)
(3) Overhead and Infrastructure: Collects information on indirect costs incurred when delivering the home visiting model
(4) Contracted Services: Collects information on costs associated with outside contracts and consultants that were used when delivering the home visiting model
(5) Model Costs, Tools, and Curricula: Collects information on costs associated with model, tools, and curricula used to deliver the home visiting model
(6) Training: Collects information on training costs incurred as part of implementing the home visiting model
(7) Consumable Supplies: Collects information on costs of consumable supplies purchased for the home visiting model
(8) Non-consumable Supplies: Collects information on purchases of non-consumable equipment and supplies used for the home visiting model; includes items purchased before the reporting period that were used during this period
(9) Travel: Collects information on travel costs associated with implementing the home visiting model

The Summary worksheet provides a summary of costs entered in the HV-BAT; no data entry is needed in this worksheet.
The Help worksheets (denoted as "Help" and "Help_overhead") provide additional guidance on how to answer selected questions in the Local Implementing Agency (LIA) Characteristics worksheet or report costs that are shared across models; no data entry is needed in these worksheets.

In the Labor Costs worksheet, we request additional information about how program staff spend their time on seven program activities. We provide definitions for each program activity below. As you complete the Labor Costs worksheet, you may find it helpful to refer to these definitions. The definitions are also shown in the Labor Costs worksheet when you hover your computer mouse over the activity name.

Program Activities for Labor Costs
(1) Service Delivery: Includes time spent providing services directly to families, such as home visits and family assessments
(2) Outreach: Includes time spent conducting outreach activities to recruit and enroll families in the program
(3) Program Management and Coordination: Includes time spent coordinating program activities and overseeing the program
(4) Supervising: Includes time spent overseeing service delivery personnel, such as home visiting staff
(5) Admin/Data Entry: Includes time spent providing administrative support, such as scheduling, data entry, and reimbursement
(6) Executive: Includes time spent by executive staff overseeing the larger program, facility, or agency
(7) Other: Includes staff roles not included in any other category (e.g., translators, cultural advisors)

Sheet 3: 1_LIA_Characteristics

Local Implementing Agency Characteristics
Instructions: In this section, please respond to the following questions about your organization's services by filling in the outlined boxes in the “Response” column. The boxes with default text “(Select one)” are dropdown menus: Click on the box to view and select an entry from the dropdown menu. Click on the gray “Help” buttons for guidance on how to answer applicable questions.


	Question		Response
1.	What are the dates of the 12-month reporting period for which the costs are reported in this tool?
		Start Date (Month, Day, Year)
		End Date (Month, Day, Year)

2.	What is the name of the home visiting model for which the costs are reported?		(Select one)	If other, provide name:

3.	How many years has your agency been implementing this home visiting model?

4.	Does your agency also implement other home visiting models?		(Select one)

4b.	If yes, which one(s)? (Select up to 5 additional models from the drop down menus)		(Select one)	If other, provide name:
			(Select one)	If other, provide name:
			(Select one)	If other, provide name:
			(Select one)	If other, provide name:
			(Select one)	If other, provide name:
5.	What are the funding sources for this home visiting model and the percentage of funding from each source?
			Funding Sources	Percentage
		Funding Source #1	(Select one)
		Funding Source #2	(Select one)
		Funding Source #3	(Select one)
		Funding Source #4	(Select one)
		Funding Source #5	(Select one)
			Total:	0%	Percentage must add up to 100%.

6.	Does this home visiting model receive outreach services from another organization free of charge? (Outreach services include family recruitment, for example, through a centralized intake and referral system.)		(Select one)


7.	In the reporting period, what percentage of this home visiting model's home visits took place in rural areas? (Click the “Help” button to see the definition of rural areas.)


8.	In the reporting period, what percentage of this home visiting model’s home visits took place in frontier areas? (Click the “Help” button to see the definition of frontier areas.)


9.	In the reporting period, what percentage of this home visiting model’s scheduled home visits were successfully completed (i.e., services were provided to the family per the evidence-based model’s guidance)?


10.	In the reporting period, what was the total number of home visits completed for this home visiting model?


11.	In the reporting period, what was the unduplicated count of households served by this home visiting model?


12.	In the reporting period, what percentage of the families served by this home visiting model were below 200% of the federal poverty line? (Click the “Help” button for guidance on federal poverty line thresholds.)


13.	For this home visiting model, approximately what percentage of visits had more than one person from your agency attending the visit (e.g., another home visitor, trainee, supervisor)?

Sheet 4: 2_Labor Costs

Labor Costs

Home Visiting Model:

(Select one)

Reporting Period:

Total Reported Labor Costs:

Instructions: Enter information on the staff who worked on this home visiting model during the reporting period.

Column A (Job Title): Enter the job title of each employee who worked on the home visiting model.

Column B (FTE Number): Enter the full-time equivalent (FTE) number of staff for whom data are being reported in this row. Include the time spent on this home visiting model only. For example—
1. For a supervisor who works full time and splits her time equally between two home visiting models, enter 0.5.
2. For an outreach coordinator who works 75% and spends all of her time on this home visiting model, enter 0.75.
You may report data for multiple staff in the same row if these staff perform similar roles. For example, for five FTE home visitors who dedicate all of their time to this home visiting model, enter 5. For five home visitors who each dedicate 50% of their time to this model, enter 2.5 (5*0.5).

Column C (Annual Salary per Person): Enter per person the annual salary amount assuming full-time status. For example, if you had five home visitors who worked 50% each with part-time salaries of $25,000 each during the year, you should enter $50,000 as the per-person annual salary. The reported amount should include salary plus fringe benefits. If fringe benefits or the fringe benefits rate is unknown, enter the salary amount and select “No” in column D.

Column D (Are Fringe Benefits Included?): From the dropdown menu, select whether fringe benefits are included in the amount reported in column C (Annual Salary). A national average fringe rate of 46% is used to inflate salary amounts that do not include fringe benefits.

Column E (Total Compensation Amount): Do not enter anything in this cell. This cell calculates the total compensation amount for each row by multiplying FTE number (column B) by the annual salary per person (column C). If fringe benefits are not included in the annual salary reported in column C, a national average fringe rate of 46% is used to inflate the salary and calculate total compensation amount.

Column F (Is Position MIECHV Funded?): From the dropdown menu, select the appropriate response about the MIECHV funding of each position. Response options include “Yes, 100%”; “Yes, partially”; and “No.”

Column G (Percentage MIECHV Funded): If “Yes, partially” is selected in column F, enter the percentage of the salary that is funded by MIECHV. Do not enter anything if “Yes, 100%” or “No” is selected in column F.

Columns H–N (Percentage Time Allocations): Enter the percentage of total time spent on the home visiting model that was dedicated to each program activity. The total percentage across activities must add up to 100%. Definitions of activities are listed in the Introduction tab and are also displayed as hover-over text for each activity name.

Column O (Total): Do not enter anything in this cell. This cell calculates the total percentage of allocations across activities. If the total does not add up to 100%, the cell will be red. If the total is 100%, the cell will be green.

Job Title
(A)

FTE Number
(B)

Annual Salary per Person (including benefits)
(C)

Are Fringe Benefits Included in Salary Amount? (D)

Total Compensation Amount =
FTE * Annual Salary (including benefits)
(E)

Is Position MIECHV Funded?
(F)

Percentage MIECHV Funded (if partial)
(G)

Program Activities

Total
(O)

Service Delivery
(H)

Outreach
(I)

Program Management/
Coordination
(J)

Supervising
(K)

Administration/Data Entry
(L)

Executive
(M)

Other
(N)

Percentage Time Allocations

(Select one)