ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
THIS IS AN EXAMPLE INVOICE / EXPENDITURE REPORT FORM. TO DOCUMENT YOUR EXPENSES, PLEASE DOWNLOAD THE BLANK TEMPLATE FOUND HERE
Please contact cdphe_covidvax@state.co.us with questions about this expenditure report form.
2
Colorado Department of Public Health and Environment
EXPENDITURE REPORT FORM
3
4
5
FEIN12-3456789Organization NameABC Primary Care
6
Purchase Order/
Encumbrance # (to be completed by CDPHE)		Expenditure Period (mm/dd/yy - mm/dd/yy)03/03/2021 - 01/31/2022
7
Payment OptionMailed CheckFinal Expense$25,025.00
8
Expenditure Report Form # (to be completed by CDPHE)1
9
10
11
To:Colorado Dept of Public Health and EnvironmentEnter Your Organization Details Below
12
CDPHE Program:N/AContact Name:Jane Doe
13
CDPHE Contact:N/AAddress:123 Main Street
14
Mail Code:N/A
15
Address:4300 Cherry Creek Drive South
16
City:DenverCity:Denver
17
State:COState:CO
18
Zip Code:80246Zip Code:12345
19
Fax:N/AFax:123-456-7890
20
Telephone:N/ATelephone:234-567-8901
21
Email:cdphe_covaxreimburse@state.co.usEmail:email@email.com
22
23
Expenditure CategoriesTotal Amount Requested from CDPHE
24
Direct Personnel Costs (description of work performed): Supporting personnel directly involved in patient engagement, such as outreach to and scheduling of patients, as well as personnel directly involved in marketing, encouraging, acquiring, administering, or reporting on the COVID-19 vaccine. This may include, but is not limited to: hiring new staff, and paying for current staff overtime.Hours WorkedHourly Pay Rate ($)Note: We have included calculations for staff time below. This level of detail is for your information only, and does not need to be included in your invoice.
25
Person A, RN - 0.5 FTE administering COVID-19 vaccine to patients. July 1, 2021 and January 1, 2022 (6 months) 480.00 30.00$14,400.00 6 months x 4 weeks per month x 20 hours per week = 480 hours
26
Person B, RN - administered COVID-19 vaccine during recurring vaccine clinics one Saturday per month between September 1, 2021 and January 1, 2022 (4 months) 28.00 30.00$840.00 4 days x 7 hours per day = 28 hours
27
Person C, Practice Administrator - 0.25 FTE advertising COVID-19 vaccine clinics on social media, calling patients who need to complete their COVID-19 vaccine series, and calling patients who are eligible to receive a booster dose. Between November 1, 2021 and January 1, 2022 (2 months) 80.00 38.50$3,080.00 2 months x 4 weeks per month x 10 hours per week = 80 hours

$80,000 salary / 2080 hours = $38.50 hourly
28
Totals - This line shows total personnel costs with hourly rate applied $18,320.00
29
Total personnel costs$18,320.00
30
Personnel Training & Development Costs (Description of work performed): Supporting training and development related to acquiring, administering, or reporting on the COVID-19 vaccine, included but not limited to: training on communications and interventions to improve immunization rates at the practice level, IT training, vaccination administration training.Hours WorkedHourly Pay Rate ($)
31
Person D, MA - Received training on reporting the COVID-19 vaccine in CIIS for regular clinic patients, and PrepMod for mass vaccination scheduling and vaccine administration. 5.00 20.00$100.00
32
Person E, MA - Received training on reporting the COVID-19 vaccine in CIIS for regular clinic patients, and PrepMod for mass vaccination scheduling and vaccine administration. 5.00 20.00$100.00
33
Totals - This line shows total personnel costs with hourly rate applied $200.00
34
Total personnel training & development costs$200.00
35
Infrastructure and Supply Costs (description of purchases and justification of need): Infrastructure and supplies needed to acquire, administer, or report on the COVID-19 vaccine, including but not limited to: development of policies and procedures, managing medical equipment, building modifications, marketing and advertising materials, storage, handling, and disposal supplies. Please note that costs related to building modifications will require prior approval. Cost ($)
36
Latex free disposable nitrile gloves (8 boxes). Sizes S - XL. PPE needed to safely administer COVID-19 vaccine. $144.55
37
1 quart sharps containers (3). Needed for proper disposal of needles used to administer COVID-19 vaccine. $105.45
38
LabRepCo Refrigerator (LHP-9-RFCSD-PH)(1); Our practice did not have a refrigerator capable of storing vaccine. This purchase was necessary for our practice to become an enrolled vaccine provider.$2,762.00
39
Total infrastructure costs$3,012.00
40
Technology Costs (description of purchases and justification of need): Technology needed to acquire, administer, or report on the COVID-19 vaccine, including but not limited to: IT upgrades, EHR modifications, system interoperability implementation, and enrollment or ongoing participation in the state Health Information Exchange and CIIS.Cost ($)
41
Latitude 5400 Chromebook Enterprise (2); Our practice required two additional laptops for staff to use to record and report vaccinations to CIIS. This purchase was necessary for our practice to adhere to vaccine provider requirements.$1,218.00
42
Total technology costs$1,218.00
43
SUB-TOTAL BEFORE INDIRECT$22,750.00
44
Indirect Costs (Description of costs): at a final rate of 10% of modified total direct costs (MTDC) for the period of March 3, 2021 through the date of submission of the invoiceCost ($)
45
Person F, Administrative Assistant - Scheduling for all patients, including COVID-19 patients, from July 1, 2021 - January 31, 2021. $2,275.00
46
Total Indirect$2,275.00
47
TOTAL THIS EXPENDITURE REPORT$25,025.00
48
Note: Your expense report (invoice) should detail how your initial payment ($25,000 or $30,000) was spent. Expense reports that do not total at least the initial payment amount risk grant funding retractions by the State. You will not receive additional funding if your expense report total exceeds your initial payment amount.
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100