Healthcare Coalition

Hospital Preparedness Program (HPP)

CDC-RFA-TP17-1701

Budget Narrative Template

July 1, 2017-June 30, 2018

NW KS HCC
Hays Medical Center (PENDING APPROVAL OF NWKSHCC )

Healthcare Coalition & Regional Hospital:

A. Personnel:

Name, Title / Annual Salary / % Effort / # Months / Amount Requested
Total Personnel

Justification: Please provide the description of responsibilities for each position listed above as they to pertain to this funding.

B. Fringe:

Name, Title / Fringe Total
Total Fringe

Description of fringe determination: Please provide information on the rate of fringe benefits used and the basis for their calculation.

C. Consultant:Total Requested: $0

This category should be used when hiring an individual to give professional advice or services (e.g., training, expert consultant, etc.) for a fee, but not as an employee. Written approval must be obtained from KDHE prior to establishing a written agreement for consultant services, and must be obtained annually in order to re-establish the written agreement. Approval to initiate or continue program activities through the services of a consultant requires submission of the following information to KDHE for each consultant:

  1. Name of Consultant: Identify the name of the consultant and describe his or her qualifications.
  2. Organizational Affiliation (if applicable): Identify the organization affiliation of the consultant.
  3. Nature of Services to Be Rendered: Describe the consultation that will be provided, including the specific tasks to be completed and specific deliverables.
  4. Relevance of Service to the Project: Describe how the consultant services relate to the accomplishment of specific program objectives.
  5. Number of Days of Consultation (basis for fee): Specify the total number of days of consultation.
  6. Expected Rate of Compensation: Specify the rate of compensation for the consultant (e.g., rate per hour, rate per day). Include a budget showing other costs (e.g., travel, per diem, supplies, and other related expenses) and list a subtotal.
  7. Method of Accountability: Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant agreement.

D. Equipment:

Item Requested / Quantity / Unit Cost / Amount
Total Equipment

Description of equipment: Please provide what the equipment will be used for and who will be using it.

E. Supplies:

Supplies / Number Needed / Unit Cost / Total
Total Supplies

Description of supplies: Above, individually list each item requested and provide the indicated information. If appropriate, general office supplies may be shown by an estimated amount per month times the number of months in the budget category. Also, provide a justification for the use of each item and relate it to specific program objectives.

F. Travel (in-State and out-of-State):

In-State Travel Purpose / Details / Total
Total In-State Travel

Description of in-state travel: Dollars requested in the Travel category should be for recipient staff travel only. Travel for consultants should be shown in the Consultant category. Travel for other participants (e.g., advisory committees, review panel, etc.) should be itemized as specified in the details below and placed in the Other category. Items needed in the detail of each budgeted trip:

  • Number of trips
  • Number of people
  • Approximate dates
  • Number of total miles
  • Cost per mile
  • Per diem
  • Lodging

Please provide a narrative justification describing the travel staff members will perform.

Out-of-State Travel Purpose / Details / Total
Travel to National Healthcare Coalition Conference x 1 person Tami Wood / Travel to San Diego for NHCC Conference Airfare 500.00, Per Diem, 300.00, Registration 450.00, Hotel, 750.00 / 2000.00
Total Out-of-State Travel / 2000.00

Description of out-of-state travel: Dollars requested in the Travel category should be for recipient staff travel only. Travel for consultants should be shown in the Consultant category. Travel for other participants (e.g., advisory committees, review panel, etc.) should be itemized as specified in the details below and placed in the Other category. Items needed in the detail of each budgeted trip:

  • Number of trips
  • Number of people
  • Approximate dates
  • Number of total miles
  • Cost per mile
  • Cost of airfare
  • Per diem
  • Lodging

Please provide a narrative justification describing the travel staff members will perform.

G. Other:

Item / Details / Total
20 HCC Members travel / 20 HCC Members travel to the National HCC Conference in San Diego Chair, Vice Chair, Secretary and 17 Caucus members to understand their roles in the HCC and to assist in planning for future projects that will benefit the NWKSHCC. 2000.00 x20=40000.00 / 40000.00
Summit Committee / Travel and per diem for Summit Committee Members to work outside of the HCC Meetings on the NWKS Healthcare Coalition Summit ( 5 Committee Members) / 3000.00
Exercise Committee / Development of Exercise Team that will produce, facilitate and evaluate exercises within the region. Travel and per diem for 10 members / 5600.00
NWKS Healthcare Coalition Preparedness Summit / Preparedness Summit featuring national speakers from the Gatlinburg Fires in TN, Kansas Fires, Joplin recovery and others decided on by the HCC Summit Committee / 6782.20
Marketing Sub-Committee / Expenses for Development of Marketing Materials, printing, travel and per diem for marketing sub-committee members / 5000.00
NWKS HCC Website Continued Development and Maintenance / Martin Ventures, Gary Martin owner. Continued development and maintenance of NWKS HCC Website. / 1600.00
HCC Meals x 4 meetings / $600.00/ meeting =2400.00 / 2400.00
Total Other

Description of other: This category contains items not included in the previous budget categories. Individually list each item requested and provide appropriate justification related to the program objectives.

H. Contractual Costs:Total Requested:

This category should be used when establishing a third-party contract to perform program activities. Written approval must be obtained from KDHE prior to establishing a written agreement. Approval to utilize funds and initiate program activities through the services of a contractor requires submission of the following information to KDHE for each contract:

  1. Name of Contractor: Identify the name of the proposed contractor and indicate whether the contract is with an institution or an organization.
  2. Method of Selection: State whether the contract is sole source or competitive bid. If an organization is the sole source for the contract, include an explanation as to why this institution is the only one able to perform contract services.
  3. Period of Performance: Specify the beginning and ending dates of the contract.
  4. Scope of Work: Describe the specific services/tasks to be performed by the contractor and relate them to the accomplishment of program objectives. Deliverables should be clearly defined.
  5. Method of Accountability: Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant agreement.
  6. Itemized Budget and Justification: Provide an itemized budget with appropriate justification. If applicable, include any indirect cost paid under the contract and the indirect cost rate used.

I. Indirect Costs:

Indirect Costs / $3493.80 / Indirect costs for accounting reconciliation and check writing, management of employee by VP of regional operations, Hays Med IT department and use of intranet. Estimated at 1.25 hr per week @ $50.00/hr.

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