Filetype Excel XLSX | Posted on 08 Aug 2022 | 3 years ago
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249x Filetype XLSX File size 0.57 MB Source: www.oregon.gov
OREGON HEALTH AUTHORITY - PUBLIC HEALTH DIVISION
VACCINE OPERATIONS TEAM - EQUITY (VOTE) | COVID-19 VACCINATION FUNDING REQUEST
Organization Name:
Contract #: Enter vaccine contract number. This contract number is separate from CARES funding. (Cell D9)
Period Start Date (dropdown):
Period End Date (dropdown): Use the dropdown below to identify your Period Start and End Date. (Cell D15)
What would you like to do? I spent additional money; I need to be paid back
(Ongoing Payment)
BREAKDOWN OF VACCINE EXPENDITURES
ALLOWABLE ACTIVITY $ Amount Requested $ Amount Documented EXPENDITURE DOCUMENTATION WILL BE REQUIRED TO BE SUBMITTED
All expenditures must be related to vaccination AT A LATER DATE
The following rows provide examples of documentation required to be submitted
with each claim. Per VOTE contract requirements, receipt(s) and related
documentation must be provided for all expenses and all amounts submitted must
be related to vaccination work.
Staff Time for the following activities:
Management, coordination, and planning
Time spent at vaccination event
Staff recruitment, management, and training of staff and
1 volunteers Payroll / Recordkeeping report documentation that ties staff time to vaccination
Outreach and/or communications work (see additional examples in column C)
Evaluation and reporting
Greeters, registration, patient, flow
Public health reporting, data entry (e.g., amount of time
taken to complete this request, administrative work)
$0.00
2 Subcontractor or Contract Work $0.00Example: Subcontractor contract, substantiation of total cost, and invoices
3 Workforce Recruitment and Training Example: Culturally specific vaccine training services invoice
$0.00
Must use applicable GSA rate for the year mileage was incurred, Copy and paste the
following url into your preferred browser for more information:
4 Mileage and Parking https://www.gsa.gov/travel/plan-book/transportation-airfare-pov-etc/privately-
Example: Mileage to and from the vaccine event owned-vehicle-pov-mileage-reimbursement-rates
Example: Map of the route (e.g. MapQuest or Google Maps)
$0.00
Outreach Materials Example: Invoices for Facebook ads, fliers, Advertising campaigns to include Public
5 Examples: Facebook ads, fliers Service Announcements, advertising costs, flyers, signs, or other items needed to
$0.00communicate or promote your vaccine event
6 Translation and Interpretation Services and/or Capabilities Example: Invoice(s) for translation services
$0.00
7 Vaccine Site Space Rental $0.00Example: Invoice from facility rented for vaccine event
Event-Required Purchases Not Otherwise Covered Above Example: Invoice or reciept for Wi-fi set up or required equipment for Wi-Fi, Invoice
8 Example: Technology to set up Wi-Fi at vaccine event, for storage unit
storage
$0.00
Supplies and Equipment Not Supplied by Federal
9 Government: Example: Receipt for masks, invoice for vaccine check-in tables
Examples: Personal protective equipment for use at vaccine
events, patient/traffic flow signage ("Enter/Exit" signs)
$0.00
10 Transportation for Patients and/or Workforce $0.00Example: Uber, Lyft or other Rideshare App receipts
Transport Supplies
11 Example: Shipment cost to receive supplies ordered for a Example: Invoice(s) or receipt(s) for shipment cost to receive supplies orded for event
vaccine event $0.00
Legal and Compliance Services
12 Example: Legal consultation to assist with permitting Example: Invoice for legal services
requirements at the vaccine event site $0.00
VOTE guidance on Administrative Overhead Costs:
1.) Indirect costs will still need to be itemized and provided in the Invoice and
Expense Report Package under “Administrative Overhead”.
Administrative Overhead Costs 2.) Items in the Administrative Overhead category will still require documentation to
13 Example: Insurance, Office space rent, Telephone charges, be submitted, supporting the expense.
Utilities used for VOTE vaccine event planning/events 3.) Items that are shared expenses with other programs at your agency can be
reimbursed based on % of Full Time Equivalent (FTE) dedicated to VOTE.
- For example: An agency cell phone which is used by an employee who dedicates
0.5 FTE toward VOTE work could be reimbursed for 50% of the monthly cell phone
bill.
$0.00
Per diem, should show breakdown based on government rate (GSA rate). Copy and
Staff costs for remote events (lodging, per diem) paste the following url into your preferred browser for more information:
14 **Excluded Cost: Hotels for those who were vaccinated** https://www.gsa.gov/travel/plan-book/per-diem-rates
Example: Invoice or receipt for staff's hotel stay
$0.00
15 Other (please include other expenses and brief explanation Example: Receipt for gift cards from grocery store
as to how it is vaccine related) $0.00 $0.00
16 Other Description: (To be Filled in by CBO if applicable)
Insert Cells Above If Additional "Other" Expenses
Required
TOTAL $0.00 $0.00
Invoice#:
OHA
Agreement #:
Date:
Organization Name
Address
Recipient City, State, Zip
Contact
Telephone
Email address
Tax ID/EIN#
Preferred: Submit Invoice to ohacovid.fema@dhsoha.state.or.us
Oregon Health Authority
Fiscal and Operations
Mail To: Attn: Finance
800 NE Oregon Street Suite 930
Portland, Oregon 97232
Description Enter description of event
Total Due $ -
Vaccine contract number (this contract number is separate from existing agreements)
"Total due" is populated based on inputs in
Tab 1 (Funding Request Form).
OREGON HEALTH AUTHORITY - PUBLIC HEALTH DIVISION
VACCINE OPERATIONS TEAM - EQUITY (VOTE) | COVID-19 VACCINATION LABOR DOCUMENTATION
Organization Name: 0
Contract #: 0
Invoice #: 0
Period Start Date: 12/30/1899
Period End Date: 12/30/1899
STEP 1
Do you have a payroll time keeping system? (use dropdown in D15)
STEP 2
Payroll Output File Name
Payroll Output $ Amount (must match amount in Payroll Output File)
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