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MAIN APPLICATION <br />b.) Program Budget Detail <br />What is the cost to deliver your project/program? List each project/program element in the table below, <br />including the cost of each element, the quantity and unit of measure, and the subtotal for each element. <br />Where necessary, allocate costs to the use of shared space, vehicles or equipment. <br />Example Program: Credit Counseling Class <br />Cost Elements <br />Cost ($) <br />Quantity /Unit of Measure <br />Subtotal ($) <br />Credit Counseling Teacher –in class <br />$25 <br />96 hours (8 hrs/mth x 12 months) <br />$2,400 <br />Credit Counseling Teacher —class prep <br />$25 <br />48 hours (4hrs/mth x 12 mths) <br />$1,200 <br />Credit Counselor — one -on -one <br />$20 <br />120 hours (10 hrs/mth x12 mths <br />$2,400 <br />Materials <br />$25 <br />120 course packets /credit reports <br />$3,000 <br />Cost Per Unit <br />$162.13 <br />Total <br />$9,000 <br />Complete the table below for the project/program for which you are requesting funds. Attach <br />additional rows /pages, as needed. <br />Program: Carrboro Community Health Center <br />Please note that the Carrboro Community Health Center is the program for which funds are being requested. <br />Please refer to the Program Budget table above to review the entire CCHC budget. Piedmont Health does not <br />routinely budget expenses based on a per encounter basis, therefore the Program Budget table above is the <br />most accurate description of how expenses are budgeted for CCHC. <br />Cost Elements <br />Cost ($) <br />Quantity /Unit of <br />measure <br />Subtotal ($) <br />Total Cost of Program <br />$4,161,541 <br />$4,929,635 <br />$2,676,539 (medical <br />dept.) <br />Total # of Units <br />25,668 encounters <br />29,314 encounters <br />20,758 medical <br />(medical + dental) <br />Total <br />encounters <br />c.) Cost per Unit – Medical Cost per Medical Visit <br />This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries <br />(households or persons) in this application and must be consistent with report submittals from previous years <br />(if applicable). <br />Revised November 20, 2014 Page <br />20 of 22 Pages <br />Actual 2014 -15 <br />Estimated 2015 -16 <br />Projected 2016 -17 <br />Total Cost of Program <br />$4,161,541 <br />$4,929,635 <br />$2,676,539 (medical <br />dept.) <br />Total # of Units <br />25,668 encounters <br />29,314 encounters <br />20,758 medical <br />(medical + dental) <br />(medical + dental) <br />encounters <br />Cost Per Unit <br />$162.13 <br />$168.16 <br />$128.94 <br />This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries <br />(households or persons) in this application and must be consistent with report submittals from previous years <br />(if applicable). <br />Revised November 20, 2014 Page <br />20 of 22 Pages <br />