Practice Change Fellows

University of ColoradoDenver

Practice Change Fellows Program

Reporting Guidelines

2008 Fellows

The Practice Change Fellows program requires semi-annual reporting from Fellows to track leadership development, project status, and financial status.

Reporting and Dispersement Schedule

Other than the initial dispersement made to Fellows at the beginning of their first year, dispersement of funds is contingent upon satisfactory performance and receipt of required reports as outlined in the Reporting and Dispersement Table below.

Reporting and Disbursement Table

As an illustrative example, the first Interim Report is due 3/31/09for the performance period of 9/1/08– 2/29/09, and the second award dispersement of $20,000 will be made 4/30/09, following receipt of that first Interim Report.

Reporting Format and Guidelines

Reports should not exceed 3 pages in length, and should include a Project and Financial Narrative Report (2 pages) and a Financial Report (1 page). An invoice for the pending dispersement and an appendix mustalso be submitted, but neither counts against the page requirements. Reporting should be succinct, focused on the period of performance, and should include all required sections. Report submission may be made via mailed original hardcopy, or emailed in electronic format.

The 2-page Project and Financial Narrative Report must be single spaced in Arial 11 point font and 1 inch margins. The 1 page Financial Report must be submitted on the attached financial report template. The invoice may be formatted appropriate to the home institution, but must include all information indicated in the instructions. The appendix should not be used to circumvent the page limitations.

UCD may withhold payment if reports are not received by the dates outlined above. Reports that are delinquent by thirty (30) days or more may result in suspension of all payment. Continued failure to submit reports by the due dates outlined above may result in termination for thePractice Change Fellows Program.

Practice Change Fellow Program Page 1 Updated 01/09

Questions regarding Project and Financial Narrative content should be directed to:

Eric Coleman, MD, MPH

Executive Director

(303) 724-2456

Questions regarding Financial Report content should be directed to:

Sandy Chalmers, MPH

Program Director

(303) 724-2443

Reports should be submitted to:

Sandy Chalmers, MPH

Program Director

Practice Change Fellows Program

13611 East Colfax Ave., Suite 100

Aurora, CO80045

(303) 724-2443

Project and Financial Narrative Reporting Instructions

The 2-page Project and Financial Narrative Report should address three sections: Fellow and Sponsoring Entity Responsibilities, Program Deliverables, and Financial status. Interim reports are for the current period of performance. The Final cumulative report will reflect the full two-year duration of the fellowship.

Project Narrative Fellow and Sponsoring Entity Responsibilities

Fellow and Sponsoring Entity responsibilities are summarized below. Progress toward meeting each of these responsibilities should be addressed in this section of the Project and Financial Narrative Report.

1. Dedicate an average of 20% of their time over the two-year award to the fellowship program activities and project execution.
2. Demonstrate a $45,000 monetary or in-kind contribution over the two-year award from the Sponsoring Entity toward project execution.
3. Attend at least 5 out of 6 of the tri-annual Practice Change Fellows Meetings over their two-year tenure in the program (unless granted special permission from the National Program Office) – indicate attended conferences.
4. Complete one project presentation at the tri-annual Practice Change Fellows Meetings – indicate date of presentation if completed.
5. Participate in the majority of peer-to-peer teleconferences – indicate topics and dates of participation.
6. Complete a formal leadership training program over their two year tenure in the program – indicate program and status of application or participation.
7. Develop a learning contract during the first year of fellowship – include current version in appendix.
8. Submit finalized two year budget to program office within 60 days after the beginning of the fellowship period - include current version in appendix.

Project Narrative Program Deliverables

During the performance period, Fellows will have developed or refined various deliverables designed to enhance their leadership abilities and to aid in execution of their project. In this section, please identify deliverables, indicate stage of development, and describe current and/or future use of the deliverable. The following deliverables should be included in the report appendix:

1. One Page Project Summary
2. Current Version of the Learning Contract
3. Business Plan
4. Brief Project Status Update(s)

Optional items for the Appendix may include but are not limited to: results of the Environmental Scan, Outcomes Measurement Plan, Conference Presentation materials, POD updates or materials.

Financial Narrative

Please use this section of the Project and Financial Narrative Report to explain any significant issues or concerns with the current financial status of your project. Any line item budget deviation in the accompanying Financial Report exceeding 10% and over $1,000 is a significant variation and requires a Budget Revision in addition to the Financial Report. The justification for the budget revision should be addressed in this section.

Financial Reporting Instructions

Financial reporting must use the attached blank Excel template. This template may be customized to match your project and currently approved Budget. Interim reports are for the current period of performance. The Final report will reflect the cumulative expenditures for the two-year duration of the fellowship.

Please indicate the currently approved Cost Categories and Project Budget for the full two years of your project. Indicate expenditure allocation for the period of performance for each funding source, and summarize those sources into the total expenditure column. Calculate the percentage of the total two-year project budget that has been expended during the reporting period. For example, each interim report covers a 6 month period, which is 25% of the two year project period. It would be expected on average to see 25% of the budget expended during each interim period, with the exception of time-specific line items such as leadership training which likely would be spent 100% within only one 6 month interim period.

The contribution for the reporting period by your Home Institution should be reflected in the report, with the understanding this amount must equal at least $45,000 by the end of your fellowship cycle. In the Financial Narrative section of the Project and Financial Narrative Report, describe any budget line item deviation exceeding 10% and over $1,000, and communications with the National Program Office to address this situation.

A mock Financial Report (in .pdf format) is attached as a demonstration of standard calculations for an interim reporting period. This is an example only – your report should be customized for your project as indicated above.

If your Financial Report reflects a need to submita Budget Revision, please discuss this in the Financial Narrative section of the Project and Financial Narrative Report, and include a revised Budget for consideration by the National Program Office.

Invoice Instructions

An invoice for payment dispersement is required with submission of each report. The invoice must be for the payment amount indicated in the Reporting and Dispersement table, and must include the invoice items described below. Please note that this in NOT an invoice template, but rather a detailed description of the items to be included in your invoice.

Invoice Items

Invoice #: Each payment invoice should have a unique identifying number of your choice

Invoice Date: This is the Report Due Date from the Reporting and Dispersement Table.

Fellow: This must be the person designated as “Fellow” in the award subcontract.

Sponsoring Entity Name and Address: This must be the entity designated as “Sponsoring Entity” in the award subcontract. This must be the same institution indicated in the W-9 form completed for award payments.

Program: This is also the program mailing address for reports and invoices.

Sandy Chalmers, MPH, Program Director

Practice Change Fellows Program

13611 East Colfax Ave., Suite 100

Aurora, CO80045

(303) 724-2443

Services: Brief description of Fellowship project and activities for the period

Amount: This is the Payment Amount from the Reporting and Dispersement Table.

UCD Subcontract Number: This is the subcontract number indicated in section 4a of your award subcontract.

UCD Award Number: This is the individual award number for the program funding indicated in section 4b of your award subcontract.

UCD Project Number: This is the individual project number for the program funding indicated in section 4c of your award subcontract.

Period: This is the Period of Performance from the Reporting and Dispersement Table. If this is the final payment, then this must be marked as such.

Certification and Phone Number: This statement is required as written on all Payment Invoices. It must be signed by the Subcontractor’s authorized official and the phone number for that person provided as indicated per section 4d and 4e of your award subcontract.

I certify that all expenditures reported (or payments requested) are for appropriate purposes and in accordance with the provisions of the application and award document.

______

Name Signature Phone Number

Mail Payment To: This is the person and address payments will be mailed to, and should be the same as indicated in section 4f of your award subcontract.

Practice Change Fellow Program Page 1 Updated 01/09