2011 Request For Proposal Cover Sheet Template Page 3

ADVERTISEMENT

STATE OF CONNECTICUT, Department of Public Health RFP # 2011-0917; Tobacco Use Cessation Services
APPLICATION FORMS
Budget Justification Schedule A
I.
Please provide a brief explanation for each line item. This must include a detailed breakdown of the
components that make up the line item and any calculation used to compute the amount.
***Please note: If Laboratory Services is a line item or subcontractor, please supply a justification as to
why a private laboratory is being used as opposed to the Connecticut State Laboratory.
II.
For contractors who have subcontracts, a brief description of the purpose of each subcontract must be
provided. Use additional sheets as necessary.
Example:
Line Item (Description)
Amount Justification including Breakdown of Costs
Travel
$730 2,000 miles @ .365 = $730.00 outreach
workers going to meetings and site visits.
Subcontractor Schedule B--Detail
I.
All subcontractors used by each program must be included, if it is not known who the subcontractor will be, an
estimated amount and whatever budget detail is anticipated should be provided. (Submit the actual detail
when it is available). A separate subcontractor schedule must be completed for each program included in the
contract. For example: The contract is providing both a Needle Exchange program and an AIDS Prevention
Education Program and Subcontractor “A” is providing services to both program there must be a separate
budget for Subcontractor “A” for each.
II. Detail of Each Subcontractor:
Choose a category below for each subcontract using the basis by which it is paid:
A. Budget Basis
B. Fee for Service
C. Hourly Rate.
Provide the detail for each subcontract referencing the corresponding program of the contract. Detail must be
provided for each subcontractor listed in the Summary.
Example A. Budget Basis
Outreach Educator $20/hr x 20hrs/wk x 50wks
$20,000
Travel 1000 miles @ .26 cents/mile
260
Supplies
500
Total
$20,760
Example B. Fee for Service:
Develop and Produce
500 Videos @ $10 each
$5,000
Total
Example C. Hourly Rate:
Quality Assurance Review of 200 Patient Charts
by Nurse Clinician 200 hours @ $25/hour
$5,000
Total
$5,000
***Please note: If Laboratory Services is a line item or subcontractor, please supply a justification as to
why a private laboratory is being used as opposed to the Connecticut State Laboratory.
RFP # 2011-0917 APPLICATION FORMS
Page 3 of 11

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business