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Sample Employee Evaluations - Excel

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					                                         SAMPLE PRO FORMA FOR DRIVING PROGRAM
                         Yr 1                                     Notes
Revenue
                                    Projected volume of evaluations & based at rate of $x for an evaluation, conference &
 Evaluations         $          -   report .
                                    Rate can be set per service provided or by an hourly rate. Note that this formula is
                                    based on a rate per service.
                                    *Add in any additional services you expect to provide in your program.

 Bad Debt            $          -   Bad debt for not-sufficient-fund checks and credit cards figured at x% of total.
                                    *Add in any additional payer types expected to reimburse for driving services.

                                    Identify percentage of business expected per payer type and typical reimbursement as
 Discount - PPO      $          -   a percentage of charges.



                                    Identify percentage of business expected per payer type and typical reimbursement as
 Discount - HMO      $          -   a percentage of charges.



 Discount -Workers                  Identify percentage of business expected per payer type and typical reimbursement as
Compensation         $          -   a percentage of charges.



                                    Identify percentage of business expected per payer type and typical reimbursement as
 Discount - Cash                    a percentage of charges. Use this if cash discount is given.


 Total Net Revenue   $          -   Total of revenue for all services minus bad debt and discounts.

Expenses
 Salary Expenses
                                    If services to be provided by an employee, project total hours for volume of services
 Salaries            $          -   projected for the year multiplied by the hourly rate of the employee.
                                     Identify the hours needed to produce the evaluation or service provided.
                                     Cost of benefits can be expressed differently in various organizations. Formula is
 Benefits                    $   -   based on benefits expressed as a per cent of salaries
 Total Salary Expense        $   -

                                     Identify all expenses outside of salaries. Make note of those expenses that will occur
 Other Non-Salary Expenses           only for start-up as these will not be included from year 2.

                                     Cost out any supply items needed such as testing materials, adaptive equipment,
 Supplies                            office supplies, etc. Annotate any expenses that will be one-time only for start-up.
  Clinic Supplies
  Minor Equipment
  Office Supplies
  Other
  Other
                                     If services are to be provided by a contractor, project total hours for volume of services
 Purchased Services          $   -   projected for the year multiplied by the hourly rate of the contractor.

   Car Maintenance                   Add in other purchased services and annotate for any start-up expenses.

   Insurance

   Gasoline

   Remodeling Expenses

   Telephone
   Utilities - Gas, Water,
Electric

   Entertainment, Food

   Training Expenses

  Travel Expenses

   Tax and License Fees

   Other
 Other
Rents and Leases                    Identify expenses for rental or lease of space or equipment.

                                    Some organizations provide an additional allocation to departments of such costs such
                                    as workers compensation insurance. Find out if this needs to be included in your
Other Indirects                     organization.

                                    Some organizations add in depreciation of capital assets over the projected life of the
Depreciation                        equipment as part of the expense equation.
Total Non-Salary Expenses   $   -

DIRECT EXPENSE              $   -   Sum of salary expenses and non-salary expenses

CONTRIBUTION MARGIN         $   -   Total net revenue minus direct expenses
                                    Key metrics are identified in column to the right. Changes to any metric will significantly
                                    change the model.


INDIRECT COST ESTIMATE      $   -   Additional cost of overhead added on by the corporation.

TOTAL COST MARGIN           $   -   Contribution margin minus indirect cost estimate.
Key Metrics
     Yr 1

              projected volume
              of service
              rate per service
              provided

              % of deduction for
              bad debt

              % of volume
              expected from
              payer type
              % of discount from
              charges
              % of volume
              expected from
              payer type
              % of discount from
              charges
              % of volume
              expected from
              payer type
              % of discount from
              charges
              % of volume
              expected from
              payer type
              % of discount from
              charges




              hourly rate for
              employee
hours projected to
deliver services
benefit rate as a %
of salaries




hours projected to
deliver services
hourly rate for
contractor
Percent markup
on direct cost
                          Yr 2
Revenue


 Evaluations          $          -




 Bad Debt             $          -




 Discount - PPO       $          -



 Discount - HMO       $          -


 Discount - Workers
Compensation          $          -




 Discount - Cash


 Total Net Revenue    $          -

Expenses
 Salary Expenses



 Salaries             $          -
Benefits                    $   -
Total Salary Expense        $   -



Other Non-Salary Expenses



Supplies




Purchased Services          $   -




Rents and Leases




Other Indirects


Depreciation

Total Non-Salary Expenses   $   -

DIRECT EXPENSE              $   -

CONTRIBUTION MARGIN         $   -
INDIRECT COST ESTIMATE   $   -

TOTAL COST MARGIN        $   -
       SAMPLE PRO FORMA FOR DRIVING PROGRAM                                  Key Metrics
                                  Notes                                          Yr 2

Projected volume of evaluations & based at rate of $x for an evaluation,
conference & report. Account for projected program growth from
marketing efforts, etc.
Rate can be set per service provided or by an hourly rate. Note that this
formula is based on a rate per service. Any anticipated rate increase
should be noted here.

*Add in any additional services you expect to provide in your program.
Bad debt for not-sufficient-fund checks and credit cards figured at x% of
total.
*Add in any additional payer types expected to reimburse for driving
services. Any changes to payer contracts that are anticipated should be
noted here.
Identify percentage of business expected per payer type and typical
reimbursement as a percentage of charges.


Identify percentage of business expected per payer type and typical
reimbursement as a percentage of charges.


Identify percentage of business expected per payer type and typical
reimbursement as a percentage of charges.

Identify percentage of business expected per payer type and typical
reimbursement as a percentage of charges. Use this if cash discount is
given.


Total of revenue for all services minus bad debt and discounts.



If services to be provided by an employee, project total hours for
volume of services projected for the year multiplied by the hourly rate of
the employee. Any anticipated rate increases for employees should be
noted here.

Identify the hours needed to produce the evaluation or service provided.
Cost of benefits can be expressed differently in various organizations.
Formula is based on benefits expressed as a per cent of salaries. Any
anticipated rate or benefit increases should be noted here.



Identify all expenses outside of salaries. Make note of those expenses
that will occur only for start-up as these will not be included from year 2.
Cost out any supply items needed such as testing materials, adaptive
equipment, office supplies, copying supplies, etc. Delete any items that
were purchased for start up only. Add in an inflation factor as
necessary.

If services are to be provided by a contractor, project total hours for
volume of services projected for the year multiplied by the hourly rate of
the contractor. Any anticipated rate increase for contractors should be
noted here.

Add in other purchased services such as remodeling space, legal fees,
utilities, telephone, insurance, car maintenance, gasoline, business
entertainment and meals, outside training, license and tax fees, etc.
Delete any items that were purchased for start up only. Add in an
inflation factor as necessary.
Identify expenses for rental or lease of space or equipment. Delete any
items that are not anticipated to carry over to year 2. Add in any
anticipated rate increases.

Some organizations provide an additional allocation to departments of
such costs such as workers compensation insurance. Find out if this
needs to be included in your organization. Add in any anticipated rate
increases.

Some organizations add in depreciation of capital assets over the
projected life of the equipment as part of the expense equation.



Sum of salary expenses and non-salary expenses

Total net revenue minus direct expenses
Key metrics are identified in column to the right. Changes to any metric
will significantly change the model.
Additional cost of overhead added on by the corporation.

Contribution margin minus indirect cost estimate.
projected volume of
service



rate per service
provided




% of deduction for bad
debt




% of volume expected
from payer type
% of discount from
charges

% of volume expected
from payer type
% of discount from
charges

% of volume expected
from payer type
% of discount from
charges



% of volume expected
from payer type
% of discount from
charges




hourly rate for
employee

hours projected to
deliver services
benefit rate as a % of
salaries




hours projected to
deliver services
hourly rate for
contractor
Per cent markup on
direct cost

				
DOCUMENT INFO
Description: Sample Employee Evaluations document sample