Background Information for Development of
Cost Estimate for I-SAT Surveys

In order to assist in the development of an accurate cost estimate for conducting I-SAT surveys for your PACE organization, please complete the fields below:

Name of PACE Organization:
Primary Contact Information / Alternate Contact Information, if applicable
Name:
Title:
Address:
Telephone:
Email: / Name:
Title:
Address:
Telephone:
Email:
PACE Center Information
How many PACE centers/sites are operated by this organization?
What is the total enrolled census at all sites?
Please complete the information on the next page for each site that will be included in the I-SAT survey for your organization.
Statistical Properties (if preference is known)
Allow CalPACE/Vital Research to propose options,
based on information provided:
Margin of Error: (5-6% recommended)
Confidence Interval: (95% is recommended) / Yes (skip to reporting preferences)
No, use the variables below:
5% 10% Other:
90% 95% Other:
Reporting Preferences
We would like an estimate for the following reporting options (please select all that apply):
Overall report - aggregates data collectively for site(s); and does not differentiate between sites
Report for each site - provides individual site reports
Report for each site, with aggregate comparison for all sites - provides separate individual site reports and an overall report
Other Items
Will you have a single point of contact (preferable) for all sites, or a different contact at each site? / Single point of contact
Different contacts at each site
N/A, we’re a single site
Have you considered partnering with other PACE programs in your state to schedule the I-SAT survey at the same time? / Yes No N/A
Please provide more information on this option, as applicable.
What is your organization’s preference for timing for the I-SAT interviews? / Fall Winter Spring Summer
Year: --- Not certain at this time

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Please enter information for each PACE center/sitein your organization that will be included in the I-SAT survey:

Name of PACE Site / Address / Location is Considered / Total Enrolled
Census / Primary Language Spoken by
At Least5% of Participants
Urban
Suburban
Rural / English
Spanish / Chinese
Korean
Other:
Urban
Suburban
Rural / English
Spanish / Chinese
Korean
Other:
Urban
Suburban
Rural / English
Spanish / Chinese
Korean
Other:
Urban
Suburban
Rural / English
Spanish / Chinese
Korean
Other:
Urban
Suburban
Rural / English
Spanish / Chinese
Korean
Other:

If you have more than 5sites, please insert more rows or attach an additional sheet.

Thank you very much for providing us with this information.Please complete the form fields on this form, save the file, and email to or fax to (323) 653-0123 to the attention of Steve Bray.A Vital Research staff member will contact with any further questions.

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