Statement of Research Activity (Schedule D)

06/26/2012

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    
             

 

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