INSTRUCTIONS ON HOW TO COMPLETE THE BUSINESS AND OPERATIONAL PLAN FUNDING APPLICATION TEMPLATE Schedule 1 -Business Plan: 5 Year Financial Forecast The costs in this Schedule are derived from the individual Fiscal Year Summaries (Schedule 2's). Schedule 2 -Operational Plan: Summary Amounts in this Schedule are a roll-up of information from the other 3 Schedules (i.e., Schedules 3 to 5) If Excel is used the embedded formulas will automatically populate the columns in this worksheet. Schedule 3 -Operational Plan: Human Resources This Schedule captures information and related costs for interdisciplinary professionals who will be providing direct services to patients and for any administrative positions required to support them. The salary scales for the interdisciplinary positions represent the maximum amount of funding the ministry is prepared to provide. Staff should be remunerated at a level below the maximum so that the Family Health Team can retain flexibility in later periods to adjust for merit increases, raises, etc. Schedule 4 -Operational Plan: Other Overhead Costs These costs represent the annual, on-going costs associated with operations and will likely need to be pro-rated for the first fiscal year. Items listed in the attached template are samples of potential costs but the list is not inclusive nor is it meant to indicate that funding must be requested for each item listed. Schedule 5 -Operational Plan: Start Up/One-Time Costs This worksheet captures information on those one-time costs associated with getting your FHT up and running. Requirements will vary from FHT to FHT depending on individual circumstances. General The Operational Plan template (i.e., Schedules 2 to 5) can be used for separate fiscal periods by simply inserting the relevant time period in each worksheet heading. Then the total for each fiscal period can be used to enter into the Business Plan 5 Year Financial Forecast template. NOTE: Only the annual totals of the Ministry Funding Request column should be included in this worksheet, e.g. the Total Cost less Community Partner Contributions and Other Sources of Funding. 1 of 6Schedule 1: Business Plan Year 1 Year 2 Year 3 Year 4 Year 5 [Insert start date] 1-Apr-06 1-Apr-07 1-Apr-08 1-Apr-09 to to to to to 31-Mar-06 31-Mar-07 31-Mar-08 31-Mar-09 31-Mar-10 Human Resources Other Overhead Costs Sub Total Operating $ $ $ $ $ Start Up/One-Time Costs Total Costs $ $ $ $ $ Year 1 -Human Resources and Other Overhead Costs should be pro-rated to reflect actual time period of funding. 5 Year Financial Forecast Ministry of Health and Long-Term Care Funding Application Template: Business Plan 2 of 6Ministry of Health and Long-Term Care Family Health Team For the Period [Insert start date to March 31, 2006 (1) (2) (3) (4) Schedule 2 -Operational Plan (Summary) Ministry Community Other Total Funding Partner Sources of Costs Request Contributions Funding (2+3+4) "M" "C" "O" Human Resources [Schedule 2] Other Overhead Costs [Schedule 3] Sub Total Operating $ $ $ $ One-Time Start Up Costs [Schedule 4] Total Costs $ $ $ $ Funding Component Legend: "M" = Funding components requested from Ministry "C" = Funding components provided by community partner contributions "O" = Funding components provided by other sources Column 1 -Total Financial requirements for the fiscal period Column 2 -Net request from Ministry (Col. 1 -(Col. 3 + Col. 4) Column 3 -Municipality, Hospital, CCAC, Private, etc. Column 4 -current MOHLTC, other provincial or federal funding Funding Application Template: Operational Plan $ASQBusiness and Operational Plan Funding Application Template.xls Sch 2 -OpPlan Summary 3 of 6Ministry of Health and Long-Term Care Family Health Team For the Period [Insert start date] to March 31, 2006 Maximum (1) (2) (3) (4) Schedule 3 -Operational Plan (Human Resources) Position Annual Method Ministry Community Other Complement Salary of Total Funding Partner Sources of Professional and Other Staff (FTE) 1 Per FTE 2 Remuneration 3 Costs Request Contributions Funding (2+3+4) "M" "C" "O" (a) Non-Physician Personnel: 4 1) 2) 3) 4) 5) 6) 7) 8) Sub Total Non-Physician Personnel $ $ $ $ (b) Physician Personnel: 5 1) 2) 3) 4) 5) 6) 7) 8) Sub Total Physician Personnel $ $ $ $ (c) Total Non-Physician & Physician Salaries $ $ $ $ (d) Benefits @20% $ $ $ $ (e) Total [to Schedule 1] $ $ $ $ 1 Position Complement determined on basis of 40 hours per week 2 Maximum Annual Salary per FTE -refer to Appendix A, "Salary Benchmarks for Interdisciplinary Health Care Providers" in the Guide to Interdisciplinary Provider Compensation regarding Ministry funding compensation levels per interdisciplinary 3Method of Remuneration -indentify basis of remuneration (salary, sessional or other) for each position 4 Non-Physician Personnel -health care providers other than Physicians and management and administrative staff 5 Physician Personnel -complete this section only if physician providers are to be remunerated on a salaried basis Funding Component Legend: "M" = Funding components requested from Ministry "C" = Funding components provided by community partner contributions "O" = Funding components provided by other sources Funding Application Template: Operational Plan $ASQBusiness and Operational Plan Funding Application Template.xls Sched 3 -OpPlan HR Page 4 of 6compensation levels per interdisciplinary position $ASQBusiness and Operational Plan Funding Application Template.xls Sched 3 -OpPlan HR Page 4 of 6Ministry of Health and Long-Term Care Family Health Team For the Period [Insert start date] to March 31, 2006 (1) (2) (3) (4) Schedule 4 -Operational Plan (Other Overhead Costs) Ministry Community Other Total Funding Partner Sources of Costs Request Contributions Funding (2+3+4) "M" "C" "O" Equipment Lease(s) 1 Equipment Service Contract(s) 1 Legal Fees Audit Fees Liability Insurance 2 Maintenance of Premises Medical Supplies Office Supplies Staff Training and Development Rent Telephone Travel Other (please describe) Total Other Overhead Costs [to Schedule 1] $ $ $ $ 1 Equipment Lease and Service Contracts -please submit separate detailed listing in support of total annual cost. 2 Insurance -do not include professional liability insurance premiums Funding Component Legend: "M" = Funding components requested from Ministry "C" = Funding components provided by community partner contributions "O" = Funding components provided by other sources Funding Application Template: Operational Plan $ASQBusiness and Operational Plan Funding Application Template.xls Sch 4 OpPlan Other Overhead Page 5 of 6Ministry of Health and Long-Term Care Family Health Team Start-up/One-Time Costs For the Period [Insert start date] to March 31, 2006 (1) (2) (3) (4) Schedule 5 -Operational Plan (Start Up/One-Time Costs) Ministry Community Other Total Funding Partner Sources of Price 3 Qty/Area (sq. ft.) Costs Request Contributions Funding (2+3+4) "M" "C" "O" (a) Clinical Equipment: 1 (b) Administrative Equipment/Furnishings (c) Leasehold Improvements/Renovations 2 (d) Other (please decribe) 4 Total Start Up/One-Time Costs [to Schedule 1] $ $ $ $ 1 Clinical equipment -provide a separate listing of requirements by provider type, e.g. Nurse Practitioner 2 Renovations/Leasehold Improvements -provide the renovated area in square feet in the Quantity column. 3 Shipping and applicable taxes should be included in the estimate 4 Practice Moving Costs -provide your transportation costs, and the address of the old and new practices. Funding Component Legend: "M" = Funding components requested from Ministry "C" = Funding components provided by community partner contributions "O" = Funding components provided by other sources Funding Application Template: Operational Plan $ASQBusiness and Operational Plan Funding Application Template.xls Sched 5 One-Time Start Up Page 6 of 6