| A | B | C | D | E | F | G | H | I | J | |
|---|---|---|---|---|---|---|---|---|---|---|
1 | PRO FORMA BUDGET TEMPLATE FOR MEDICAL SCHOOL RESIDENCY AND FELLOWSHIP SLOTS | |||||||||
2 | ||||||||||
3 | *Program Name: | *Finance Director Name: | ||||||||
4 | *Program Contact: | *Finance Director Signature and Date of Approval: | ||||||||
5 | *Accreditation Status: | *Department Chair Name: | ||||||||
6 | *Department Chair Signature and Date of Approval: | |||||||||
7 | *Medical School CFO Name: | |||||||||
8 | *Medical School CFO Signature and Date of Approval: | |||||||||
9 | ||||||||||
10 | ASSUMPTIONS: | |||||||||
11 | *Proposed duration of overall residency and fellowship program in number of years: | |||||||||
12 | *Duration of individual residency and fellowship slot in number of years: | |||||||||
13 | *# of new residency and fellowship FTEs requested / year: | |||||||||
14 | *% increase salary and fringe each year: | |||||||||
15 | ||||||||||
16 | REVENUE Must be support listed from at least one source. Add rows where necessary | FY 21 | FY 22 | FY 23 | FY 24 | FY 25 | Five Year Total | |||
17 | ||||||||||
18 | Hospital Support (list each site, how much, how long) | |||||||||
19 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
20 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
21 | Department (list name of department, how much, how long) | |||||||||
22 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
23 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
24 | UMP - Clinical or Academic Transfer | |||||||||
25 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
26 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
27 | Foundation (list each separately - who, how much, how long) | |||||||||
28 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
29 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
30 | Grant (list each separately - who, how much, how long) | |||||||||
31 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
32 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
33 | OTHER (list and describe in detail who, how much, how long) | |||||||||
34 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
35 | $ - | $ - | $ - | $ - | $ - | $ - | ||||
36 | ||||||||||
37 | *TOTAL REVENUE (must cover total expenses listed below) | $ - | $ - | $ - | $ - | $ - | $ - | |||
38 | ||||||||||
39 | Administrative Expenses Add rows where necessary | |||||||||
40 | FY 21 | FY 22 | FY 23 | FY 24 | FY 25 | Five Year Total | ||||
41 | *ACGME Required Program Director FTE Minimum: | |||||||||
42 | *Program Director Salary/Benefits | $ - | $ - | $ - | $ - | $ - | $ - | |||
43 | *ACGME Required Program Coordinator FTE Minimum: | |||||||||
44 | *Program Coordinator Salary/Benefits | $ - | $ - | $ - | $ - | $ - | $ - | |||
45 | *ACGME Required APD FTE Minimum: | |||||||||
46 | *APD Salary/Benefits | $ - | $ - | $ - | $ - | $ - | ||||
47 | Administrative Overhead | $ - | $ - | $ - | $ - | $ - | $ - | |||
48 | Computers (Coordinator/Resident/Fellow (@$xxx each) | Policy | $ - | $ - | $ - | $ - | $ - | $ - | ||
49 | Technology Maint. Fees (@$1300.00 /comp/yr) | $ - | $ - | $ - | $ - | $ - | $ - | |||
50 | *SUBTOTAL | $ - | $ - | $ - | $ - | $ - | $ - | |||
51 | ||||||||||
52 | Educational Expenses | |||||||||
53 | Staff CME | $ - | $ - | $ - | $ - | $ - | $ - | |||
54 | *Resident/Fellow Salaries | Stipends | YOY % Increase Forecast | $ - | $ - | $ - | $ - | $ - | $ - | |
55 | *Resident/Fellow Benefits | Benefits | $ - | $ - | $ - | $ - | $ - | $ - | ||
56 | Health Insurance | YOY % Increase Forecast | $ - | $ - | $ - | $ - | $ - | $ - | ||
57 | Disability | $ - | $ - | $ - | $ - | $ - | $ - | |||
58 | SS & MC Taxes | $ - | $ - | $ - | $ - | $ - | $ - | |||
59 | Life Insurance | $ - | $ - | $ - | $ - | $ - | $ - | |||
60 | Parking | $ - | $ - | $ - | $ - | $ - | $ - | |||
61 | CME/Other Educational Fees (@ $xxx per fellow) | $ - | $ - | $ - | $ - | $ - | $ - | |||
62 | Clinical and Research Conferences (weekly w/food) | $ - | $ - | $ - | $ - | $ - | $ - | |||
63 | Educational Materials | $ - | $ - | $ - | $ - | $ - | $ - | |||
64 | *SUBTOTAL | $ - | $ - | $ - | $ - | $ - | $ - | |||
65 | ||||||||||
66 | Marketing Expenses | |||||||||
67 | Recruitment | |||||||||
68 | Advertising (ad in NEJM 1/8th page run 4 times) | $ - | $ - | $ - | $ - | $ - | $ - | |||
69 | *SUBTOTAL | $ - | $ - | $ - | $ - | $ - | $ - | |||
70 | ||||||||||
71 | Other (please list and describe in detail): | |||||||||
72 | Accreditation Fees | $ - | $ - | $ - | $ - | $ - | ||||
73 | Other | $ - | $ - | $ - | $ - | $ - | $ - | |||
74 | *SUBTOTAL | $ - | $ - | $ - | $ - | $ - | $ - | |||
75 | ||||||||||
76 | *TOTAL EXPENSE | $ - | $ - | $ - | $ - | $ - | $ - | |||
77 | (Total of Subtotals; Should Equal Revenue) | |||||||||
78 | ||||||||||
79 | Share of total expenses above that are fixed and already part of Department's baseline budget | |||||||||
80 | ||||||||||
81 | Share of total expenses that are variable/incremental to new FTE slots and require new funding | |||||||||
82 | * Denotes required fields | |||||||||