This instrument was developed for the National Long-Term Care Channeling Demonstration. This project was conducted by Mathematica Policy Research, Inc. under contract #HHS-100-80-0157 and Temple University under contract #HHS-100-80-0133 for the Department of Health and Human Services (HHS) Office of Social Services Policy (now Office of Disability, Aging and Long-Term Care Policy), as well as additional funding from the HHS Health Care Financing Administration (now Centers for Medicare and Medicaid Services) and HHS Administration on Aging. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.
| NOTE: This is a recreation of this form. See the PDF version for a scanned version of the actual form. |
| SCHEDULE D STATEMENT OF RESEARCH ACTIVITY FOR MONTHENDING _________________________ NAME OF ORGANIZATION _________________________ STATE _________________________ | |||
| RESEARCH ACTIVITIES | ESTIMATED STAFF HOURS THIS MONTH | ||
| SITE DIRECTOR | PROFESSIONAL STAFF (CASE MGRS. etc.) | CLERICAL PARA-PRO- FESSIONAL & OTHER | |
| 1. Advisory or resource group meeting with MPR | |||
| 2. Interview, discussions, or correspondence with MPR including QC and liaison contacts (phone or in-person) | |||
| 3. Contact with providers and community to explain research data needs (Does not include normal provider and community relations activity). | |||
| 4. Time spent reproducing, shipping and document control for forms sent to MPR (eg. screens, baseline assessments, and client tracking) | |||
| 5. Other | |||
| NOTE: Do not include estimates of (1) Time spent on outreach and screening for the control group (2) Time for research-only questions in assessment instrument (3) Time spent in randomization calls (4) Time spent on informed consent procedures Separate estimates of thse costs will be made by MPR using data from other sources such as time sheets. | |||
| Standard Form 1034 7 GAO 5000 1034-114 | PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL CONTINUATION SHEET | VOUCHER NO. | ||||
| SCHEUDULE NO. | ||||||
| SHEET NO. | ||||||
| U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT AND LOCATION | ||||||
| NUMBER AND DATE OR ORDER | DATE OF DELIVERY OR SERVICE | ARTICLES OR SERVICES (Enter description, item number of coutract or Federal supply schedule, and other information deemed necessary) | QUAN- TITY | UNIT PRICE | AMOUNT | |
| COST | PER | |||||