Form 3 The Workforce Program Awardee Cost Workbook

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Overview

Cost Workbook Instructions
A. Project Reporting Year
B. Personnel
C. Labor Allocation
D. Contracted Services
E. Target Pop. Information
F. Buildings and Facilities
G. Supplies and Materials
H. Other Costs
I. New Overhead, Admin Charges
J. Attrition amd Turnover

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Sheet 1: Cost Workbook Instructions

Cost Workbook Instructions and Collection Forms
The Evaluation of Programs Supporting the Mental Health of the Health Professions Workforce Cost-Benefit Assessment being conducted by NORC at the University of Chicago aims to understand the costs and potential benefits of the Health and Public Safety Workforce Resiliency Training Program (HPSWRTP) and the Promoting Resilience and Mental Health among Health Professional Workforce (PRMHW) program. Our ability to measure the impact of your program depends on the clarity of the information that you provide. HRSA is invested in learning about costs and potential benefits of your organization’s activities to help inform future funding opportunities. Instructions: To streamline this process, NORC has reviewed your available grant application, progress and performance reports, and budget forms and pre-filled each sheet of the cost workbook with the information that your team provided in the project application, non-competing Continuation (NCC) reports, annual performance reports (APR), and other budget related forms or reports provided to HRSA. Please review this information and adjust as necessary to ensure complete and accurate cost reporting. The cost workbook is broken down into the following sections. A separate cost workbook file will be provided to you for each project year. Section A – Project Year. Identifies the project year corresponding to the activities reported in the workbook. Each cost workbook will encompass the costs associated with one year of grantee project activities. Section B – Personnel. Captures name, role, and labor expense for paid, contract, and in-kind employees supporting the grantee project. Section C – Labor Allocation. Divides the time each person spent supporting the project by activities related to intervention development, intervention delivery, recruitment, evaluation and research, and/or management and other HPSWRTP/PRMHW related activities. Section D – Contracted Services. For grantee project related services delivered by contracted organizations. Divided into broad categories related to repair and maintenance, security, advertising/marketing, or other services. Section E – Participant Information. Captures the number of participants by profession type and particular training activity, as defined by each grantee. Section F – Facility Costs. Costs the grantee project incurred to use, rent, or otherwise pay for space and facility related costs for the project reporting period. Section G – Supplies and Materials. Collects costs of materials including software, office supplies, local travel related costs, etc. Section H – Other Costs. Includes costs not captured in other categories including continuing education fees or costs, out-of-town related travel expenses, participant incentives, and/or training fees, etc. Section I – Overhead and Administrative Charges. Indirect costs and fringe benefits. Section J – Attrition and Turnover. Public Burden Statement: The purpose of this information collection is to evaluate federal programs designed to support the mental health and resiliency of the healthcare and public safety workforce. 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 0915-XXXX and is valid until MM/DD/20XX. Public reporting burden for this collection of information is estimated to average xx 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.
OMB Control Number: 0915-XXXX Expiration Date: MM/DD/20XX

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Sheet 2: A. Project Reporting Year

Cost Workbook Instructions and Collection Forms
Section A: Project Reporting Year
Instructions: The information provided in this cost workbook corresponds to the project reporting period shown below. A separate cost workbook form will be used for each project year in which the intervention was conducted and for which you have complete records. Cost related data has been abstracted and pre-filled into each sheet of this form using information your team provided in the project application, Awardee Training and Services Form, Non-competing Continuation (NCC) reports, annual performance reports (APR), and other budget related forms or reports provided to HRSA. Please review each sheet of this file and provide any and all adjustments necessary to ensure accuracy and validity of the included cost data.
The data in this spreadsheet corresponds to the following time period:
	Project year		Start date:	1/1/20XX
	Project year		End date:	12/31/20XX
(A separate cost workbook file will be used for each reporting year of grantee projects)
Please answer all subsequent questions in this spreadsheet as they pertain to the dates entered above.

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Sheet 3: B. Personnel

Cost Workbook Instructions and Collection Forms
Section B: Personnel
Instructions: In this sheet, please provide information about all staff and in-kind employees who worked on this [Insert program name] during [time period reported in Sheet A]. If you need to add additional rows for paid employees, contractors, or volunteers, please right-click on the row number for the last row in the table and select "Insert". Please use the following definitions: For section B1, we define a "paid employee" as an individual who receives a W-2, who works either part- or full-time for the organization and has a role in developing and/or administering the intervention. Your organization pays federal and state payroll taxes for this individual. For section B2, we define a "contracted employee" as an individual who receives a 1099, who works either part- or full-time for the organization and has a role in developing and/or administering the intervention. Please include only contracts with people. Contracts for services are covered in Sheet D. For section B3, we define an "in-kind employee" as an individual who is either a volunteer or an employee, who conducts activities on behalf of the intervention, but is not being paid through the grant.
Section B1.
For each paid employee that participated in the project, please review their total annual labor expense (including fringe benefits and payroll taxes) during the time period reported in Sheet A [insert reporting time period]. Please also review and adjust the number of months of the year that person was assigned to the [insert awardee project name]. For example: • A person who worked part- or full-time on the [insert awardee project name] for the entire year would have worked 12 months on the [insert awardee project name]. • A person who joined the organization in July and worked on the [insert awardee project name] through December would have worked on the [insert awardee project name] for six months. • A person who pitched in on the [insert awardee project name] for July through August while someone else was out on maternity leave would have worked two months on the [insert awardee project name], even if they worked for the organization the entire year. • A person who is a listed employee on the [insert awardee project name] but did not perform any work for the project would have worked zero months on the [insert awardee project name], even if they worked for the organization the entire year.
Table B1. Paid Staff Employees
	Staff	Role/Title	Total Annual Labor Expense (including fringe benefits and payroll taxes)	Months of the Year Worked on HPSWRTP/ PRMHW	% Time on HPSWRTP/ PRMHW
	Paid Employee 1
	Paid Employee 2
	Paid Employee 3
	Paid Employee 4
	Paid Employee 5
	Paid Employee 6
	Paid Employee 7
	Paid Employee 8
	Paid Employee 9
	Paid Employee 10
	Do you need more rows?
Section B2.
Please list each contracted employee using the same method described above for paid employees.
Note: Include only contracts with persons. Contracts with companies are reported in Sheet D.
Table B2. Contracted Employees
	Staff	Role/Title	Total Annual Labor Expense (including fringe benefits and payroll taxes)	Months of the Year Worked on HPSWRTP/ PRMHW	% Time on HPSWRTP/ PRMHW
	Contracted Employee 1
	Contracted Employee 2
	Contracted Employee 3
	Contracted Employee 4
	Contracted Employee 5
	Contracted Employee 6
	Contracted Employee 7
	Contracted Employee 8
	Contracted Employee 9
	Contracted Employee 10
	Do you need more rows?
Section B3.
Please report any in-kind employees or volunteers who supported your intervention using the same method described above for paid employees.
Table B3. In-kind Employees
	Staff	Role/Title	Total Annual Labor Expense (including fringe benefits and payroll taxes)	Months of the Year Worked on HPSWRTP/ PRMHW	% Time on HPSWRTP/ PRMHW
	In-kind Employee 1
	In-kind Employee 2
	In-kind Employee 3
	In-kind Employee 4
	In-kind Employee 5
	In-kind Employee 6
	In-kind Employee 7
	In-kind Employee 8
	In-kind Employee 9
	In-kind Employee 10
	Do you need more rows?

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Sheet 4: C. Labor Allocation

Cost Workbook Instructions and Collection Forms
Section C. Labor Allocation
Instructions: In this sheet, please provide information about how the staff and volunteers listed on Sheet B spend their time. If you need to add additional rows for paid employees, contractors, or volunteers, please right-click on the row number for the last row in the table and select "Insert". The first column is pre-populated from Sheet B during [time period reported in Sheet A]. Subsequent columns identify the percentage of intervention time spent on each category of service.
Section C1.
For each paid employee, please report the estimated percent of their time spent on each of the categories of service. Each employee’s estimated total should sum to 100% (calculated in the last column) even if they only worked on the intervention project part time.
Table C1. Paid Employee Percent Intervention Time
	Employee	Intervention Development	Intervention Delivery	Participant Recruitment	Evaluation and Research	Management and Other HPSWRTP/ PRMHW	% Time allocated (sum to 100%)
	Paid Employee 1						0		It would be good to embed the formula into the spreadsheet so awardees can quickly see if everything sums to 100%
	Paid Employee 2						0
	Paid Employee 3						0
	Paid Employee 4						0
	Paid Employee 5						0
	Paid Employee 6						0
	Paid Employee 7						0
	Paid Employee 8						0
	Paid Employee 9						0
	Paid Employee 10						0
Section C2.
For each contracted employee, please report the estimated percent of their time spent on each of the categories of service during [time period reported in Sheet A]. Each employee’s estimated total should sum to 100% (calculated in the last column) even if they only worked on the intervention project part time.
Table C2. Contracted Employee Percent Intervention Time
	Contractor	Intervention Development	Intervention Delivery	Participant Recruitment	Evaluation and Research	Management and Other HPSWRTP/ PRMHW	% Time allocated (sum to 100%)
	Contracted Employee 1						0
	Contracted Employee 2						0
	Contracted Employee 3						0
	Contracted Employee 4						0
	Contracted Employee 5						0
	Contracted Employee 6						0
	Contracted Employee 7						0
	Contracted Employee 8						0
	Contracted Employee 9						0
	Contracted Employee 10						0
Section C3.
For each in-kind employee, please report the estimated percent of their time spent on each of the categories of service during [time period reported in Sheet A]. Each employee’s estimated total should sum to 100% (calculated in the last column) even if they only worked on the intervention project part time.
Table C3. In-kind Employees
	In-kind	Intervention Development	Intervention Delivery	Participant Recruitment	Evaluation and Research	Management and Other HPSWRTP/ PRMHW	% Time allocated (sum to 100%)
	In-kind Employee 1						0
	In-kind Employee 2						0
	In-kind Employee 3						0
	In-kind Employee 4						0
	In-kind Employee 5						0
	In-kind Employee 6						0
	In-kind Employee 7						0
	In-kind Employee 8						0
	In-kind Employee 9						0
	In-kind Employee 10						0

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Sheet 5: D. Contracted Services

Cost Workbook Instructions and Collection Forms

Drop Downs

Section D. Contracted Services

Intervention Development

Yes

Instructions: If your intervention had contracts with companies/corporations to provide services supporting the intervention during [time period reported in Sheet A], enter that information in D1, below. This differs from the information captured in Section C which is focused on contracts with an individual person. If your intervention had a contract with a person, then that information should have been entered in sections B2 and C2 in Sheets B and C, respectively.

Intervention Delivery

No

Notes: An example of a contract for services would be a contract with a software vendor to provide texting services, a van service to provide transportation, advertising/marketing, or medically related services. Contracted services for behavioral health/substance use services would also fall under this category.

Participant Recruitment

Table D1. Contracted Services by Amount and Category

Evaluation and Research

Management

Other HPSWRTP/PRMHW

Contracted Service

Amount

Which Service Category should this Contract be allocated to?*

Notes/Comments?

Total (all contracts)

$0.00

* The dropdown list contains the following categories: 1) Intervention Development, 2) Intervention Delivery, 3) Participant Recruitment, 4) Evaluation and Research, 5) Management, and 6) Other HPSWRTP/PRMHW related services

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Sheet 6: E. Target Pop. Information

Cost Workbook Instructions and Collection Forms
Section E. Target Population Information
Note to reviewers: The questions will be changed to reflect the target professional groups listed by each grantee – each grantee will see only those groups they have listed as their targets within applications and periodic reports. Additionally, the training program choices will be adjusted to fit each grantee’s project according to the Awardee/Grantee Training and Services Report. If there are other participant or training categories that need to be added, grantees will have that option. Lastly, data from Annual Performance Reports (APR) will be used to pre-fill the fields in Table E and grantees will be asked to verify and adjust as needed to ensure reporting accuracy.] Instructions: Please provide information about the number and type of participants within the target population who have enrolled and took part in the training(s) during [time period reported in Sheet A]. If you need to add additional rows for profession types not listed, please right-click on the row number for the last row in the table and select "Insert".
Table E. Target Population Information
			Training/Activity/Service/Initiative A	Training/Activity/Service/Initiative B	Training/Activity/Service/Initiative C	Insert additional columns as needed
	E1.	What was the total number of participants enrolled during [the time period reported in Sheet A] by training/acvitity/service/iniaitive?
	E2.	How many nurses were enrolled in each training/activity/service/initiative during [the time period from Sheet A]?
	E3.	How many physicians were enrolled in each training/activity/service/initiative during [the time period from Sheet A]?
	E4.	How many physician assistants were enrolled in each training/activity/service/initiative during [the time period from Sheet A]?
	E5.	How many behavioral health providers were enrolled in each training/activity/service/initiative during [the time period from Sheet A]?
	E6.	How many other medical staff were enrolled in each training/activity/service/initiative during [the time period from Sheet A]?
	E7.	How many non-medical staff were enrolled in each training/activity/service/initiative during [the time period from Sheet A]?

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Sheet 7: F. Buildings and Facilities

Cost Workbook Instructions and Collection Forms
Section F. Facility Costs
Instructions: This section asks about the cost of the facilities used for the [insert awardee project name] during [time period reported in Sheet A].
	F1.	Did you pay for space or facilities used for the intervention?
			Yes/No		If NO, skip to Sheet G.
	F2.	What percentage of the space was used for the intervention? For example, if the space was used for multiple purposes, what estimated percentage of space or facilities was used for the intervention?
			Percentage	%
	F3.	What was the annual cost (rent or mortgage payments) for the space you acquired?
			Total	$
	F4.	What categories best describes the service you used this facility for (select all that apply)
			Select

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Sheet 8: G. Supplies and Materials

Cost Workbook Instructions and Collection Forms
Sheet G: Supplies and Materials
Instructions: Please list the total costs of supplies and materials used by the intervention during [time period reported in Sheet A].
Notes: You may list itemized costs, add rows for items that are excluded from the list, or simply provide the total amount, if known.
Table G. Total Costs of Supplies and Materials for [time period reported in Sheet A]
			Expense		Amount
			a.	Software Expense
			b.	Office Supplies
			c.	IT Network/Computer related
			d.	Snacks, Food, Decoration
			e.	Gasoline (for employees)
			f.	Transit/Bus Fees (for employees)
			g.	Other items
			h.	Total	$0.00

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Sheet 9: H. Other Costs

Cost Workbook Instructions and Collection Forms
Section H. Other Costs
Instructions: Please review and verify the information about the following additional costs. If not applicable to your intervention, please leave it blank.
Table H. Costs Associated with Expense Categories during [time period reported in Sheet A]
		a.	Communications (e.g., telephone, postage, printing, ads, subscriptions)
		b.	Intervention related participant transportation (e.g., providing participants transportation to and from the intervention; subsidizing participant costs for transportation to and from the intervention) (if not contracted services)
		c.	Staff training fees
		d.	Staff out of town travel for awardee meeting or research and evaluation
		e.	Staff out of town travel for intervention related reasons
		f.	Gift Cards/incentives for participants
		g.	Continuing education fees or costs
		h.	Any other costs not yet accounted for in this questionnaire
		Total		$0.00

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Sheet 10: I. New Overhead, Admin Charges

Cost Workbook Instructions and Collection Forms

Drop Downs

Section I. Overhead and Administrative Charges

Yes

Instructions: For each type of cost, please review and verify whether overhead costs are included (and update if not accurate). For costs where overhead is included, please provide the overhead rate and identify what the overhead costs pay for. The Notes/Comment column may be used to provide additional explanation about the overhead rate.

No

Notes: If you have any questions about how these numbers were calculated, please contact XX, XX@norc.org.

Not Applicable

Table I. Overhead and Administrative Charges

Category

Costs include overhead?

Overhead rate

What is this rate intended to pay for?

Notes/Comments

Labor - Employee (Section C)

Labor - Contractor (Section C)

Contracted Services (Section D)

Buildings and Facilities (Section F)

Supplies and Materials (Section G)

Other Costs (Section H)

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Sheet 11: J. Attrition amd Turnover

Cost Workbook Instructions and Collection Forms
Section J. Attrition and Turnover
[The profession category will be changed to reflect the target groups listed by each grantee – each grantee will see only those groups they have listed as their targets within applications and periodic reports. If there are other categories that need to be added, grantees will have that option.]
Instructions: For each professional group, please provide the number of staff members per the instructions for each reporting category. If you need to add additional rows for profession types not listed, please right-click on column letter I and select "Insert". If you are working with partner organizations, we understand you may not have access to this information across organizations. If that is the case, please reach out to NORC at XXXX@norc.org for assistance. If you are able to complete this for only part of your target population, please explain in the text box below Table J.
Table J. Attrition and Turnover
	Profession - general professional category of employees working at the grantee organization.	Nurses	Physicians	Physician Assistants	Behavioral Health Providers	Other Medical Staff	Non-Medical Staff	Total
	Number Employed at Start of Project Year - number of individuals employed by the organization at the start of the reporting period.							0
	Number of Positions Recruited for - number of positions the organization sought to fill over the course of the reporting period.							0
	Number of New Staff Hired - the number of new staff hired over the course of the reporting period.							0
	Number that Left the Organization - number of staff who left the organization during the reporting period.							0
	Number of Employees that Participated in the Program - the number of employees that participated in the employee resiliency program.							0
	Number of Employees that Left the Program - the number of employees that left the employee resiliency program.							0
	Number of Employees that Participated and Left the Organization - the number of employees that participated in the employee resiliency program AND left the grantee organization by the end of the reporting period.							0