| Cost Data Collection Instruments for Trauma-Specific Evidence-Based Programs Cost Workbook |
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| Overview | |||||||||
| Please scroll down to read all information for a general overview of the survey. | |||||||||
| What is this survey about? | |||||||||
| This survey is for organizations implementing trauma-specific evidence-based programs (EBPs). Examples of trauma-specific EBPs include Parent-Child Interaction Therapy, Seeking Safety, and Trauma-Focused Cognitive Behavioral Therapy. The survey is designed to gather information on the value of all resources used by an agency to implement the trauma-specific EBP. These might include resources that the program does not pay for directly and that might not reflect in budgets or expenditure records (such as the value of volunteer time or donated office space). | |||||||||
| How is the survey organized? | |||||||||
| The survey is organized into nine sections labeled A to J. Each section asks questions about a specific type of cost or resource and appears as a separate tab in this Excel workbook. Tab J asks questions about costs related to program start-up (initial planning and implementation of the trauma-specific EBP). 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 does the survey cover? | |||||||||
| On Tab B to Tab I, please report costs for the time period selected for your cost analysis. (This period is often the most recently completed fiscal year.) The survey refers to the time period you select as the “reporting period.” Please specify your reporting period on Tab A. Tab J incudes questions about start-up costs, which your agency may have incurred prior to the reporting period used in the rest of the survey. Start-up costs are resources or expenditures that were related to the initial planning and launch of trauma-specific EBP services. |
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| 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 might be helpful to review the entire survey before starting to identify the kinds of information required. (To print the entire survey, click Print and select the Entire workbook option under Print settings.) |
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| Who 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 might have to consult with other people in the agency to gather information required to address some questions. | |||||||||
| How do I move 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 the appropriate fields. Some fields contain drop-down lists to select responses (indicated by the entry "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. |
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| This data collection tool has been developed by Mathematica, under contract to the U.S. Department of Health and Human Services, Administration for Children & Families, Contract No. HHSP233201500035I/HHSP23337026T, and is being issued for public use without the need to request permission of use from Mathematica. However, the tool is provided on an “AS IS” basis, and Mathematica makes no representations or warranties of any kind, express or implied, as to the operation of the tool, or to any information, content, materials, or other services made available to you through the download of this tool, unless otherwise specified in writing. You expressly agree to use the tool at your own risk. | |||||||||
| PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, ACF is gathering data on the costs of implementing Trauma-Specific Evidence-Based Programs (TS-EBPs). Public reporting burden for the described this collection of information is estimated to average 8 hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is XXXX-XXXX and the expiration date is XX/XX/XXXX. If you have any comments on the described collection of information, please contact Dori Sneddon at Dori.Sneddon@ACF.hhs.gov. | |||||||||
| SECTION A: YOUR AGENCY | ||||||||||||
| This section requests basic information about your agency, the time period for cost information you provide, and the trauma-specific EBP for which you are reporting costs. Please scroll down to answer all questions (A1 to A6). | ||||||||||||
| A1. | What is the official name of your agency? | |||||||||||
| A2. | What is the name of the trauma-specific EBP for which you are reporting costs in this survey? | |||||||||||
| A3. | Please provide contact information for the person primarily responsible for completing this survey. | |||||||||||
| Name | ||||||||||||
| Position/Title | ||||||||||||
| Telephone | ||||||||||||
| Address | ||||||||||||
| A4. | What is the period for which you are reporting costs (the “reporting period”) in sections C to J? This period should be the 12 months of your agency's most recently completed fiscal year. Note: the start-up costs will cover a different time period. | |||||||||||
| [Enter month] | [Enter Year] | TO | [Enter month] | [Enter Year] | ||||||||
| A5. | What were your agency's total expenditures for this reporting period (including all programs/services)? | |||||||||||
| A6. | If any unusual circumstances affected expenditures 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. | |||||||||||
| 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 staff members who spent time on activities related to the trauma-specific EBP during the reporting period. Please scroll down to answer all questions (B1 to B4). | |||||||||||
| B1a. | Using the following table, please indicate expenditures for salaries and fringe benefits for staff positions of the trauma-specific EBP during the reporting period. Include positions for any staff who spent time on the trauma-specific EBP. This should include staff involved in program management and planning, delivery of direct services to clients, communication and outreach, professional development and training, fidelity monitoring, evaluation activities, and administrative functions (for example, accounting, grant management, and so on). For each position, please enter the following: - The position or job title for each person - The initials of each staff person - The amount paid to the staff member during the reporting period - The average number of hours worked per week - The number of weeks the person was employed and paid during the reporting period - The amount of payroll taxes and fringe benefits for each employee as a percentage of salary or as a total dollar amount. If your center only has a total amount paid for all employees, please record this amount in the workbook under explanatory notes at the bottom of this sheet (question C4). - The approximate percentage of time each staff member spends on TS EBP activities using the results from the staff survey/time log, if available. If the staff member spends all her or his time on TS EBP services, enter 100%. |
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| Staff position/title | Staff member initials | Amount paid during the reporting period | If reporting information for individual staff members: | Payroll taxes and fringe benefits (enter as a percentage of salary or as a total dollar amount) | Approximate percentage of time allocated to trauma-specific EBP activities | ||||||
| Average number of hours worked per week | Number of weeks paid during the reporting period | Value as a percentage of salary | or | Total amount paid in dollars | |||||||
| Example: Therapist | J.D. | $35,000.00 | 40 | 52 | 32% | or | 100% | ||||
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| B1b. | 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. | ||||||||||
| B2. | Please indicate which payroll taxes and fringe benefits are included in the figures reported in Table B1a. 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] | ||||||||||
| B3a. | Did your organization incur costs for overtime paid to staff members listed above during the reporting period? (Please select YES or NO from the drop-down list.) | ||||||||||
| [Click here and select from list] | |||||||||||
| B3b. | If you answered YES to question B3a, please enter the total cost of overtime paid to staff members listed above during the reporting year. | ||||||||||
| [Enter dollar amount here.] | |||||||||||
| B4. | Please use the space below to enter any explanatory notes for the information provided in this section. | ||||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | |||||||||||
| SECTION C: CONTRACTED SERVICES | |||||||||
| This section asks questions about services purchased to support implementation of the trauma-specific EBP from organizations or people who operate independently. These services might include training on trauma-specific EBP implementation, other professional development education or training, consultation or clinical supervision services, administrative services, and so on. Please scroll down to answer all questions (C1 to C2). | |||||||||
| C1a. | Did your agency contract with a company, organization, individual consultant, or other professional to provide services for the trauma-specific EBP during the reporting period? Please use the drop-down box to select YES or NO. | ||||||||
| [Click here and select from list] | |||||||||
| C1b. | If you answered YES to question C1a, please use the table below to enter information on the contracted services purchased and their cost during the reporting period. Please enter a separate line for each type or category of service, even if a contractor provided multiple types of services. If your records provide only 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 service purchased | Expenditure amount (dollars) | Percentage of cost allocated to the trauma-specific EBP | Description or additional notes | |||||
| Example: Contractor XYZ | Training | $5,000.00 | 100% | Conducted initial training for staff | |||||
| Total expenses for contracted services during the reporting period, in dollars (if services are not itemized above): | |||||||||
| C2. | Please use the space below to provide information on calculations and data sources or other explanatory notes for this section. | ||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | |||||||||
| SECTION D: VOLUNTEER LABOR | ||||
| This section asks about the value of any labor donated to implement the TS-EBP (by volunteers or staff from other agencies) during the reporting period. Please scroll down to answer all questions (D1 to D3). | ||||
| D1. | Did any volunteers help your agency provide TS-EBP services during the reporting period? Please select YES or NO from the drop-down list. | |||
| [Click here and select from list] | ||||
| D2a. | If you answered YES to question D1, please use the table below to estimate the value of donated labor. For each volunteer, please enter the following: - position or job description - number of hours the volunteer(s) worked per month - number of months the volunteer(s) worked during the reporting period - your best estimate of the hourly wage that a person paid for this work would receive |
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| Position or job description | Number of hours volunteer worked per month | Number of months volunteer worked during the reporting period | Estimated hourly wage for paid employee (dollars) | |
| Example: Volunteer A - engages children in play-based activities in common area while therapist meets one-on-one with parent | 4.0 | 4.0 | $12.00 | |
| D2b. | Please describe the sources of information for this section, including estimates of hourly wages. | |||
| D3. | Please use the space below to enter any additional explanatory notes on the information provided in this section. | |||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | ||||
| SECTION E: SUPPLIES AND MATERIALS | ||||||
| This section asks questions about the cost or value of supplies and materials used to implement the trauma-specific EBP during the reporting period. Please scroll down to answer all questions (E1 to E4). | ||||||
| E1. | Using the following table, please indicate the cost of all supplies and materials purchased to implement the trauma-specific EBP during the reporting period. For the purposes of this survey, supplies and materials are items used and replenished regularly. Examples of supplies and materials include educational materials, office supplies, assessment instruments, workbooks, and toys or other items used during the delivery of clinical services. Please enter the total estimated cost for the item(s) listed. For example, if you purchased various toys and supplies with a total value of $300, please enter the total expenditure of $300. For each item listed, please estimate the percentage of the cost to be allocated to the trauma-specific EBP. For example, if the item was used about half the time for implementing the trauma-specific EBP and half the time for another purpose, please enter 50 percent. If the item was used only to implement the trauma-specific EBP, please enter 100 percent. |
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| Item | Description | Quantity | Total expenditure amount for all items (dollars) | Estimated percentage of cost for the trauma-specific EBP | ||
| Example: Toys and art supplies | Miscelleaneous toys and supplies for use in therapy sessions | 1 | $300.00 | 50% | ||
| E2. | Did your program receive any donated supplies or materials used to implement the trauma-specific EBP in the last reporting period? Please use the drop-down list to select YES or NO. |
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| [Click here and select from list] | ||||||
| E3. | If you answered yes to question E2, please list the donated items in the following table. Please also estimate how much you would have paid for the item if purchased. Please enter the total estimated cost for the item(s) listed. For example, if you received two television monitors worth $150 each, please enter $300, the cost for both monitors. For each item listed, please estimate the percentage of the cost to be allocated to the trauma-specific EBP. For example, if the item was used about half the time for implementing the trauma-specific EBP and half the time for another purpose, please enter 50 percent. If the item was used only to implement the trauma-specific EBP, please enter 100 percent. |
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| Item | Description | Quantity | Approximate total cost of all items if purchased | Percentage of cost allocated to the trauma-specific EBP | ||
| E4. | Please use the space below for any explanatory notes on the information provided in this section. | |||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | ||||||
| SECTION F: EQUIPMENT | |||||||||
| This section asks questions about durable equipment or capital assets used to implement the trauma-specific EBP during the reporting period. Please scroll down to answer all questions (F1 to F4). | |||||||||
| F1. | Please use the table below to list any durable equipment used to implement the trauma-specific EBP during the reporting period. For the purposes of this survey, durable equipment includes items with an expected useful life of more than one year. Examples include computer systems, automobiles, office furniture, and so on Please indicate the following: - The type equipment used - The number of items - The year the equipment was purchased or received (if information is available) - The original purchase price or estimated value of equipment received at no cost (in dollars) - The expected useful life of the equipment at the time of purchase or receipt (the number of years the equipment will be used before replacement) For each item listed, please also estimate the percentage of cost that should be allocated to the trauma-specific EBP. For example, if the item was used about half the time for implementing the trauma-specific EBP and half the time for another purpose, please enter 50 percent. If the item was used only for implementing the trauma-specific EBP, please enter 100 percent. |
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| Description of equipment or asset | Quantity | Year purchased or received | Original purchase price per item (dollars) | Expected useful life at time of purchase (number of years) |
Percentage of cost allocated to trauma-specific EBP | ||||
| Example: Computers | 3.00 | 2013 | $900.00 | 5.0 | 20% | ||||
| F2a. | Was any equipment leased or rented to support implementation the trauma-specific EBP during the reporting period? Please use the drop-down list to select YES or NO. | ||||||||
| [Click here and select from list] | |||||||||
| F2b. | If you answered YES to question F2a, please use the table below to enter the type of equipment leased or rented, the total amount paid during the reporting period, and the percentage of the cost to be allocated to the trauma-specific EBP. | ||||||||
| Description of equipment leased or rented | Quantity | Total amount paid during the reporting period (dollars) | Percentage of cost allocated to trauma-specific EBP | ||||||
| Example: Computers | 3.00 | $900.00 | 20% | ||||||
| F3a. | Did the center receive any donated equipment that was used to implement the trauma-specific EBP during the reporting period? Please use the drop-down list to select YES or NO. | ||||||||
| [Click here and select from list] | |||||||||
| F3b. | If you answered yes to question F3a, please use the table below to enter the type of equipment donated, the approximate cost if the equipment had been purchased, and the percentage of the cost to be allocated to the trauma-specific EBP. | ||||||||
| Description of equipment donated | Quantity | Estimated cost if equipment had been purchased (dollars) | Expected useful life at time of donation (number of years) | Percentage of cost allocated to trauma-specific EBP | |||||
| Example: Computers | 3.00 | $900.00 | 5.0 | 20% | |||||
| F4. | Please use the space below to provide information on calculations and data sources or other explanatory notes for this section. | ||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | |||||||||
| SECTION G: FACILITIES | ||||||||||||||
| This section asks questions about cost of office space or other facilities used by your trauma-specific EBP during the reporting period. Please scroll down to answer all questions (G1 to G4). | ||||||||||||||
| G1. | Please use the following table to list all buildings or other facilities regularly used to implement the trauma-specific EBP during the reporting period, including office space and offsite facilities. Include facilities used free of charge or for below market rates. For each building or facility, please indicate the following: - The building or facility name - A brief description of the use of the building - Whether your agency paid to use the building or space or if it was used at no cost to the agency For facilities that the agency paid to use: - The total amount paid during to use the building/facility during the reporting period (through mortgage, rent, or lease payments) - The percentage of the building space used to implement the trauma-specific EBP For buildings that were used at no cost to the agency: - The total size of the building (in square feet) - The size of space(s) used to implement the trauma-specific EBP (in square feet) OR the percentage of the building space used to implement the trauma-specific EBP - The frequency that the facility was used for trauma-specific EBP services during the reporting period (number of days per week) |
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| Building or facility name | Brief description of use of the building | Did the agency pay to use this facility or was it received as an in-kind donation? | BUILDINGS OR FACILITIES AGENCY PAID TO USE | BUILDINGS OR FACILITIES USED AT NO COST TO THE AGENCY | ||||||||||
| Amount paid to use building during the reporting year (dollars) | Percentage of total building space used to implement the trauma-specific EBP | Number of days per week this space was used for providing trauma-specific EBP services | Total size of building (square feet) |
Size of space used to implement the trauma-specific EBP (square feet) | or | Percentage of total building space used to implement the trauma-specific EBP | Number of days per week this space was used for providing trauma-specific EBP services | |||||||
| Example 1 | Community center | One room used to deliver group therapy | Received in kind | 4000 | 400 | or | 0.5 | |||||||
| Example 2 | Office | Program staff use this space to conduct adminstrative tasks such as case file documentation | Paid | $24,000.00 | 25% | 1.00 | or | |||||||
| Building 1 | [Click here and select from list] | or | ||||||||||||
| Building 2 | [Click here and select from list] | or | ||||||||||||
| Building 3 | [Click here and select from list] | or | ||||||||||||
| Building 4 | [Click here and select from list] | or | ||||||||||||
| G2. | What was the total amount the center paid for utilities (for example, gas and electric, water) in this facility during the reporting period? (If the utilities are provided at no cost to the center, please enter 0.) | |||||||||||||
| [Enter dollar amount here.] | ||||||||||||||
| G3a. | Was the amount paid for utilities by the center subsidized? In other words, did the center pay less than market rate for utilities? | |||||||||||||
| [Click here and select from list] | ||||||||||||||
| G3b. | If you answered yes to question G3a, please describe the source of the subsidy (for example, “The center paid a flat amount for utilities to the organization that owns the building.”) | |||||||||||||
| G4. | Please use the space below to provide information on calculations and data sources or other explanatory notes for this section. | |||||||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | ||||||||||||||
| SECTION H: MISCELLANEOUS | |||||
| This section is for recording any costs not reported already in other tabs. You should list any outstanding items or services used by your trauma-specific EBP during the reporting period. Please scroll down to answer all questions (H1 to H2). | |||||
| H1. | Using the following table, please enter the cost or estimated value of all miscellaneous items and services purchased or received to support trauma-specific EBP implementation during the reporting period and not reported elsewhere in the survey. If your agency received any miscellaneous items free of charge, please enter 0 under Expenditure and estimate what your agency would have paid to purchase them. Examples of miscellaneous items include fees paid to program developers, travel costs related to service delivery (transportation/mileage), travel costs not related to service delivery (for example, costs associated with professional development, training, and conferences), incentives, and so on. If the item or service supported multiple programs, please estimate the percentage of the cost to be allocated to the trauma-specific EBP (for example, based on the proportion of time it was used to support the trauma-specific EBP). |
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| Description of item or service | Expenditure (dollars) | Estimated value (if item received at no cost) | Percentage of cost allocated to trauma-specific EBP | ||
| Example: Mileage reimbursements to staff delivering the trauma-specific EBP | $1,500.00 | 100% | |||
| H2. | Please use the space below to provide details on calculations and data sources or other explanatory notes for this section. | ||||
| 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 might 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 (I1 to I7). |
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| I1. | Does your agency calculate indirect costs 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] | |||||||||||
| I2a. | If you answered YES to question I1, please enter the established indirect cost rate your agency used during the reporting period. | ||||||||||
| Agency indirect cost rate (percentage): | |||||||||||
| I2b. | 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] | |||||||||||
| I3a. | Does your agency calculate indirect costs without using an established indirect cost rate? Please select YES or NO from the drop-down list. | ||||||||||
| [Click here and select from list] | |||||||||||
| I3b. | If your agency calculates indirect costs for the trauma-specific EBP 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: | |||||||||||
| I4a. | If your agency calculated total indirect costs during the reporting period, please enter that amount below. | ||||||||||
| Total calculated indirect costs for the reporting period (dollars): | |||||||||||
| I4b. | If your agency calculated total indirect costs during the reporting period, please estimate the percentage of cost allocated to the trauma-specific EBP. | ||||||||||
| Percentage of cost allocated to the trauma-specific EBP: | |||||||||||
| I5. | Do indirect costs reported on this tab cover items or services 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] | |||||||||||
| I6. | Please itemize below the items or services covered under indirect costs, indicating any items or services reported in other sections of the survey. | ||||||||||
| I7. | Please use the space below to enter any explanatory notes on the information provided in this section. | ||||||||||
| PLEASE SAVE AND CONTINUE TO THE NEXT SECTION. | |||||||||||
| SECTION J: START-UP COSTS | |||||||||||
| This section asks about costs that that your agency incurred to begin delivering the trauma-specific EBP. Please include only costs associated with launching the program (for example, costs related to initial training of staff or initial purchase of materials required for trauma-specific EBP implementation). For this section, please define and report costs for the start-up period: the period of time when your agency incurred costs associated with launching the program. The beginning of this period might coincide with the date that your agency first received funding to provide the TS EBP or first began taking steps to prepare to deliver the TS EBP. (It is likely that the start-up period will begin no more than 12 months before you began delivering services.) The end of the start-up period might coincide with the date your agency began delivering services or within 3 months of that date. Your agency might have incurred start-up costs before the reporting period used for the rest of this survey. Please scroll down to answer all questions (J1 to J10). |
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| J1. | In what month and year did your agency first begin providing the trauma-specific EBP? | ||||||||||
| [Enter month] | [Enter year] | ||||||||||
| J2a. | What is the period for which you are reporting start-up costs (the “start-up period”)? Please see the instructions above for guidance on defining this period. | ||||||||||
| [Enter month] | [Enter Year] | TO | [Enter month] | [Enter Year] | |||||||
| J2b. | Please describe briefly the factors or activities you considered in defining the start-up period (for example, the timing of funding or other activities related to launching trauma-specific EBP services). | ||||||||||
| J3. | Please use the table below to enter information on personnel time contributed to the start-up of program services during the start-up period, if you have this information available. This might include time spent on program planning, hiring staff, arranging for resources such as space and supplies, providing oversight, providing or receiving staff training, implementing changes to administrative data systems, and travel time. This table should include all staff who contributed toward program start-up activities. If you record information regarding the staff time spent during the start-up period, please use a table similar to the one in item B1a on Tab B (Salaries and Fringe) to record information related to the compensation of these staff members during the start-up period. | ||||||||||
| Staff position/title | Staff member initials | Estimated number of hours spent on program activities during the start-up period | Description of actvities or additional notes | ||||||||
| Example: Therapist | J.D. | 60 | Provided staff training | ||||||||
| J4. | Please use the table below to enter information on contracted services purchased to support start-up of the trauma-specific EBP. Please include only contracted services required for launching the program (for example, contracted services related to initial training of staff). | ||||||||||
| Name of contractor or service provider | Type of service purchased | Expenditure amount (dollars) | Description or additional notes | Year purchased | |||||||
| Example: Contractor XYZ | Training | $5,000.00 | Conducted initial training for staff | 2015 | |||||||
| J5. | Using the table below, please indicate the cost of supplies and materials purchased during the start-up period to support trauma-specific EBP services. For the purposes of this survey, supplies and materials are items used and replenished regularly. Examples of supplies and materials include educational materials, office supplies, and toys or other items used during the delivery of clinical services. For each item listed, please estimate the percentage of the cost to be allocated to the trauma-specific EBP. For example, if the item was used about half the time for implementing the trauma-specific EBP and half the time for another purpose, please enter 50. If the item was used only to implement the trauma-specific EBP, please enter 100. |
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| Supply or material | Expenditure amount (dollars) | Description or additional notes | Year purchased | Percentage of cost allocated to the trauma-specific EBP | |||||||
| Example: Toys and art supplies | $300.00 | Miscelleaneous toys and supplies for use in therapy sessions | 2015 | 50% | |||||||
| J6. | Please use the table below to itemize any durable equipment purchased to support start-up of trauma-specific EBP services. Please include items that were purchased or donated to the agency. For the purposes of this survey, durable equipment includes items with an expected useful life of more than one year. Examples include computer systems, automobiles, office furniture, and so on. Please indicate the following: - The equipment or asset used (and the number of items included) - The year the equipment was purchased or received (if information is available) - The original purchase price or estimated value of equipment received at no cost (in dollars) - The expected useful life of the equipment at the time of purchase (the number of years the equipment will be used before replacement) For each item listed, please also estimate the proportion of cost that should be allocated to the trauma-specific EBP. For example, if the item was used about half the time for implementing the trauma-specific EBP and half the time for another purpose, please enter 50. If the item was used only for implementing the trauma-specific EBP, please enter 100. |
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| Description of equipment or asset (including number of items) | Year purchased or received | Original purchase price (dollars) | Expected useful life at time of purchase (number of years) |
Percentage of cost allocated to trauma-specific EBP | |||||||
| Example: Computers | 2015 | $900.00 | 5.0 | 50% | |||||||
| J7. | Please use the table below to report the facility-related costs required for start-up of trauma-specific EBP services (for example, facilities improvements). Please indicate the expected useful life of the facility or facility improvement (the number of years the facility or improvement can be used before replacement). | ||||||||||
| Facility-related cost | Expenditure amount (dollars) | Description or additional notes | Year cost incurred | Expected useful life of facility at time cost incurred (number of years) | Percentage of cost allocated to trauma-specific EBP | ||||||
| Office | $24,000.00 | Program staff use this space to conduct adminstrative tasks such as case file documentation | 2015 | 20 | 20% | ||||||
| J8. | Please use the table below to report any miscellaneous costs incurred for start-up of trauma-specific EBP services. For each item listed, please estimate the percentage of the cost to be allocated to the trauma-specific EBP. For example, if the item was used about half the time for implementing the trauma-specific EBP and half the time for another purpose, please enter 50. If the item was used only to implement the trauma-specific EBP, please enter 100. |
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| Item | Expenditure amount (dollars) | Description or additional notes | Year purchased | Percentage of cost allocated to the trauma-specific EBP | |||||||
| Example: Mileage reimbursements to staff delivering the trauma-specific EBP | $1,500.00 | 2015 | 100% | ||||||||
| J9. | Are any of the start-up costs reported in this section also reported in other sections of the survey? If so, please indicate which costs are also reported in other sections. | ||||||||||
| J10. | Please use the space below to enter any additional explanatory notes on the information provided in this section. | ||||||||||
| THIS IS THE END OF THE COST WORKBOOK. THANK YOU FOR YOUR PARTICIPATION IN THE DATA COLLECTION. | |||||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |