Additional Document Requests Template

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					                          FY '11 Capital Template Instructions
                          Oregon Health & Science University
                          FY '11 Capital ROI Template Instructions



The following document is to assist in the completion of the OHSU Capital ROI Template for the FY '11 Capital Budgeting Cycle.


There are FIVE sections within this workbook. They are as follows:

  1)   Instructions
  2)   ROI Worksheet
  3)   Detail Cost Estimate
  4)   Capital Request Form
  5)   Total Year 0 Capital Expenditures (or Total Project cost)

Depending on the nature of your request, there may be certain sections which could be excluded from your capital request. Please
see the FY '11 Capital Budget Guidelines, for further reference, on the CFS Budgeting website
(http://ozone.ohsu.edu/financial/budget/index.shtml).

Reminder: All capital requests (regardless of dollar value) must be entered into UBS (University Budget Solution).

Instructions on how to use template:

To begin, please review the FY '11 Capital Budget Guidelines and these Instructions.
Once your review complete, identify which template and which sections will be required for your FY '11 capital request.

Additional Instructions - ROI worksheet:

  A.   Fill in all required input fields. These cells are shaded in green.

       Enter in the title of your request - "Sample Project."
       Enter in all implementation costs and ongoing costs/benefits for departments involved.
       Enter in the name of the department that will be impacted as a result of this request.
       Ensure to reflect all capital and operating costs in their respected sections.
       Adjust / enter in any factors needed on ongoing costs/benefits.
       Ensure to reflect all ongoing costs/benefits by respective area impacted.

  B.   After entering in all implementation costs and ongoing costs/benefits for departments involved, you can adjust
       the outgoing years, if necessary, to accurately reflect the cash flow impact of activity.

  C.   All other data will be populated automatically. No other input on this form is necessary.

Note: Financial calculations are set for only University projects. If Hospital is also impacted, rate may need to be adjusted upon review.

Additional Instructions - Detail Cost Estimate

  A.   Name / Phone #, Department, and Date is linked to fields on the capital request form. No need to enter
       on this form.

  B.   Prior Year Capital Expenditures and FY 2011 Requested Capital will be populated by linked cells. (These should be
       reviewed for reasonableness)

  C.   Enter in any expected requested capital for FY 2011 through FY 2015. This will be used to update and
       be coordinated within the Five-Year plan.

  D.   Enter the anticipated Funding Source and amount in total. If more than one, please list all impacted.


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                         FY '11 Capital Template Instructions
                         Oregon Health & Science University
                         FY '11 Capital ROI Template Instructions



  E.   Enter in the anticipated start and completion date of request.

  F.   Indicate whether a return on capital investment is required. List specifically any details qualifying the exclusion.

 G.    Obtain appropriate signatures. Approvals can be obtained by including those individuals on the email submitting
       the request. If they are visible on the email, it will be assumed they are aware and approve of the capital request.


Additional Instructions - Capital Request Form

  A.   Enter in the Name / Phone #, Department, and Date of request. These fields are linked to other forms.
       Enter in the Strategic Initiative Tactic #, if applicable.

  B.   Enter a detailed description for each of the sections listed. They are as follows:

       Project / Capital Request Description
       Justification for Project / Capital Request - Potential Risks / Alternatives
       Does this request fulfill a commitment?
       Is this request legally required? (Cite regulation/specifics)
       How does this request advance key strategies?
       Other Factors / Assumptions
       Indicate the reason for Project / Capital Request. Select boxes that apply.

       Keep in mind, this form will be included will all other details provided. This is the section for you to provide
       the basis for your request. This form will be reviewed and considered heavily in the process.


Additional Instructions - Total Year 0, if applicable

  A.   If your project will take multiple years to complete, this is where you will enter in all costs associated with
       your project in the specific fiscal year it is anticipated.

       These totals will link to the ROI worksheet as total "Year 0" capital expenditures which as defined as all
       costs required and expected to be needed in order to compete request capital activity.


While working on this workbook, please save often! This may help reduce rework of schedules.

Also, you may attach any support you feel necessary to this workbook. Please send this file to Gene Whiteley-Ross,
(whiteleg@ohsu.edu) as soon as complete and approved.

Once sent, please print out a copy of all schedules for your records. Once received, all files will be accumulated and
submitted to the CAC for review.

As always, if you have any questions or comments, please call Gene @ ext. #47158. He will work to
resolve your concerns or issues in order to complete this required documentation.

Thanks in advance for all your hard work and consideration of these matters.




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                                                                                              OHSU CAPITAL ROI FORM - Economic Life: 10 Years
                                                                                                             Sample Project

NOTE: Please review the FY 11 Capital Budgeting Guidelines, once available. This form may not be necessary for certain requests over $50k, exceptions will be listed within Guidelines. Requests under $50k do not require a workbook.

                                                                            Year 0 **        FY 2011      FY 2012       FY 2013        FY 2014        FY 2015         FY 2016        FY 2017        FY 2018         FY 2019        FY 2020
                  Implementation Costs
    ITG                                                                          Input                                               Implementation Financial Impact - Automatically Updated

Capital Expenses                                         CK
Salaries - Capitalized Labor                                                             -            -         -               -             -               -              -              -               -              -                   -
Contract Labor                                                                           -            -         -               -             -               -              -              -               -              -                   -
Professional Services                                                                    -            -         -               -             -               -              -              -               -              -                   -
Capital Equipment                                                                        -            -         -               -             -               -              -              -               -              -                   -
Building Improvements                                                                    -            -         -               -             -               -              -              -               -              -                   -
Software                                                                                 -            -         -               -             -               -              -              -               -              -                   -
Hardware                                                                                 -            -         -               -             -               -              -              -               -              -                   -
Freight                                                                                  -            -         -               -             -               -              -              -               -              -                   -

Operating Expenses
Salaries & Wages - Operating (under $100k)                                               -
Minor Equipment                                                                          -
Maintenance                                                                              -
Training                                                                                 -
Other Expenses                                                                           -
    Other Department: _____________________

Capital Expenses                                         CK
Salaries - Capitalized Labor                                                             -            -         -               -             -               -              -              -               -              -                   -
Contract Labor                                                                           -            -         -               -             -               -              -              -               -              -                   -
Professional Services                                                                    -            -         -               -             -               -              -              -               -              -                   -
Capital Equipment                                                                        -            -         -               -             -               -              -              -               -              -                   -
Building Improvements                                                                    -            -         -               -             -               -              -              -               -              -                   -
Software                                                                                 -            -         -               -             -               -              -              -               -              -                   -
Hardware                                                                                 -            -         -               -             -               -              -              -               -              -                   -
Freight                                                                                  -            -         -               -             -               -              -              -               -              -                   -

Operating Expenses
Salaries & Wages - Operating (under $100k)                                               -
Minor Equipment                                                                          -
Maintenance                                                                              -
Training                                                                                 -
Other Expenses                                                                           -

Total Project Outlay                                                                     -
Total Expected Depreciation                                                                           -         -               -             -               -              -              -               -              -                   -

                                                                                             FY 2011      FY 2012       FY 2013        FY 2014        FY 2015         FY 2016        FY 2017        FY 2018         FY 2019        FY 2020

          Operating Costs - Benefits/Ongoing            Input                Factor           Input             Benefit Impact - Automatically updated. (If needed, can override with additional/expected benefites in future years)
   ITG Benefits

Additional Revenue                                       0%         0 % growth                        -         -               -             -               -              -              -               -              -                   -
"Real Wage" Savings (Include OPE)                        3%         3 % inc. assumed                  -         -               -             -               -              -              -               -              -                   -
Contractor savings                                              -   Assume 1 time                     -
Cost Avoidance (Labor, Supps, etc.)                             -   Assume 1 time                     -
Supply savings                                           0%         0 % growth                        -         -               -             -               -              -              -               -              -                   -
Rent\Lease (assumes no step increases)                   0%         0 % growth                        -         -               -             -               -              -              -               -              -                   -
Other Savings                                                   -   Assume 1 time                     -
Productivity/Efficiency Savings                          0%         0 % growth                        -         -               -             -               -              -              -               -              -                   -

   Departmental Benefits

Additional Revenue                                       0%         0 % growth                        -         -               -             -               -              -              -               -              -                   -
"Real Wage" Savings (Include OPE)                        3%         3 % inc. assumed                  -         -               -             -               -              -              -               -              -                   -
Contractor savings                                              -   Assume 1 time                     -
Cost Avoidance (Labor, Supps, etc.)                             -   Assume 1 time                     -
Supply savings                                           0%         0 % growth                        -         -               -             -               -              -              -               -              -                   -
Rent\Lease (assumes no step increases)                   0%         0 % growth                        -         -               -             -               -              -              -               -              -                   -
Other Savings                                                   -   Assume 1 time                     -
Productivity/Efficiency savings                          0%         0 % growth                        -         -               -             -               -              -              -               -              -                   -

Total Incremental Savings                                                                             -         -               -             -               -              -              -               -              -                   -

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                                                                                                   OHSU CAPITAL ROI FORM - Economic Life: 10 Years
                                                                                                                  Sample Project

NOTE: Please review the FY 11 Capital Budgeting Guidelines, once available. This form may not be necessary for certain requests over $50k, exceptions will be listed within Guidelines. Requests under $50k do not require a workbook.

                                                                            Year 0 **            FY 2011               FY 2012            FY 2013                FY 2014       FY 2015          FY 2016           FY 2017          FY 2018           FY 2019          FY 2020

                                                           Input             Factor                Input                                                                       Cost Impact - Automatically updated

   ITG Costs

Wages (Include OPE)                                          3%     3 % inc. assumed                       -                    -                   -                  -             -                   -                -                 -                 -               -
Software Licensing/Maintenance                               0%     0 % growth                             -                    -                   -                  -             -                   -                -                 -                 -               -
Other expenses                                               0%     0 % growth                             -                    -                   -                  -             -                   -                -                 -                 -               -
Maintenance                                                  0%     0 % growth                             -                    -                   -                  -             -                   -                -                 -                 -               -
Rent\Lease (assumes no step increases)                       0%     0 % growth                             -                    -                   -                  -             -                   -                -                 -                 -               -

   Departmental Costs

Wages (Include OPE)                                          3%     3 % inc. assumed                       -                    -                   -                  -             -                   -                -                 -                 -               -
Software Licensing/Maintenance                               0%     0 % growth                             -                    -                   -                  -             -                   -                -                 -                 -               -
Other expenses                                               0%     0 % growth                             -                    -                   -                  -             -                   -                -                 -                 -               -
Maintenance                                                  0%     0 % growth                             -                    -                   -                  -             -                   -                -                 -                 -               -
Rent\Lease (assumes no step increases)                       0%     0 % growth                             -                    -                   -                  -             -                   -                -                 -                 -               -

Total Incremental Costs                                                                                    -                    -                   -                  -             -                   -                -                 -                 -               -

Net Benefit/Expense Impact                                                                0                -                    -                   -                  -             -                   -                -                 -                 -               -

Net Benefit/Expense Impact w/o productivity savings                                       0                -                    -                   -                  -             -                   -                -                 -                 -               -

                                                                     ITG Costs/Benefits                    -                    -                   -                  -             -                   -                -                 -                 -               -
                                                                     Dept. Costs/Benefits                  -                    -                   -                  -             -                   -                -                 -                 -               -

                                                                     Total Cost/Benefit                    -                    -                   -                  -             -                   -                -                 -                 -               -
                                                                     chk                                       -                    -                   -                  -             -                   -                -                 -                 -               -




                                                                                                                                                                                             ** Year 0 represents the total anticipated costs for all fiscal years.
                              Includes Productivity Increases (Soft Savings)                                                                                                                 If project exceeds multiple years, combine all costs into Year 0.
                                                                                                                      OHSU                                                                   Please see the tab at the end of workbook for Year 0 schedule.
Net Present Value @ OHSU - Combined Hurdle Rate **                                        0                         Hurdle Rate
                                                                                                                                                                                                                 Depreciable Lives - Legend
Internal Rate of Return                                                                0.00%                                 8.53% OHSU - Combined                                                                 Type                               Years

Payback Period: Sum of Years / Average                                                         years                                                                                         ITG Salaries & Wages                                             3.0
                                                                                                                                                                                             Contract Labor                                                  3.0
                                                                                                                   ** Rate may need to be adjusted upon review                               Professional Services                                           3.0
                                                                                                                                                                                             Capital Equipment                                               7.0
                              Without Productivity Increases (Soft Savings)                                                                                                                  Building Improvements                                          10.0
                                                                                                                      OHSU                                                                   Software                                                        3.0
Net Present Value @ OHSU - Combined Hurdle Rate **                                        0                         Hurdle Rate                                                              Hardware                                                        5.0
                                                                                                                                                                                             Freight                                                          7.0
Internal Rate of Return                                                                0.00%                                 8.53% OHSU - Combined
                                                                                                                                                                                             If another depreciable life is deemed necessary, please contact
Payback Period: Sum of Years / Average                                                         years                                                                                         CFS - Budgets and changes can be made to workbook.

                                                                                                                   ** Rate may need to be adjusted upon review




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                                                           OHSU CAPITAL DETAIL COST ESTIMATE
   Name, Phone #:                                                                       Department:                                                         Date:



A completed ROI is required on all capital requests over $50,000. The details supplied below will assist the Capital Allocation Committee in its allocation of
capital budget. Please complete and return to Gene Whiteley-Ross, CFS - Capital Budget Manager, as soon as completed.


                                                          Total Capital Request - University Only                                                       Funding Sources

                         Prior Year                                                                                     Total Anticipated
   Request Title          Capital             FY2011          FY2012      FY2013          FY2014            FY2015           Capital      Funding Source               $ Amount
                        Expenditures                                                                                     Expenditures

Sample Project                        -               -            -                -              -               -                        -   Unrestricted                           -


              Anticipated Start Date:                                                                        Expected Completion Date:



                                                                       Detailed Cost Estimate - Total Project

     Quantity                     Item Description                                      Total Cost                     Summary of Implementation Exps                 Total Cost

Capital Expenditures
          1            Salaries - Capitalized Labor                                                    0               Total Capital Cost                                                  0
          1            Contract Labor                                                                  0               minus Hospital Capital Cost                                         0
          1            Professional Services                                                           0               Total University Capital Cost                                       0
          1            Capital Equipment                                                               0
          1            Building Improvements                                                           0
          1            Software                                                                        0               Operating Expenses                                                  0
          1            Hardware                                                                        0               minus Hospital Operating Expenses                                   0
          1            Freight                                                                         0               Total University Operating Expenses                                 0

Operating Expenditures
          1            Salaries & Wages - Operating (under $100k)                                      0
          1            Minor Equipment                                                                 0
          1            Maintenance                                                                     0               Previously Authorized and Expected Spent                    -
          1            Training                                                                        0
          1            Other Expenses                                                                  0               TOTAL HOSPITAL PROJECT COST                                         0
                                                                                                                       TOTAL UNIVERSITY PROJECT COST                                       0


                       TOTAL PROJECT APPROVAL AMOUNT                                                   0               TOTAL OHSU PROJECT COST                                             0




                                                                         Return on Capital Investment

Return Required (Please check one)                                          Yes                                                                        No

   If no, list category (safety, regulatory, etc.):

FINANCIAL RETURN

First Year Savings/Earnings:                              $                     -                                             Second Year Savings/Earnings: $                      -

Estimated Economic Life                                           10.0 Years
IRR (without productivity savings)                              0.00%


By signing, you agree that to the best of your knowledge: 1) The financial information is accurate. 2) The ROI is calculated correctly. 3) I understand my
unit will receive the expense, capital and benefits noted. 4) You are committing to funding all capital within your capital allocation for the specified year(s). 5)
You are committing OHSU to accomplish the benefits noted.

              APPROVALS
Name                                                      Signature                                        Title                                                    Date




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                                                              OHSU CAPITAL REQUEST FORM


   Name, Phone #:                                                                 Department:                                         Date:




Request Title:        Sample Project
Strategic Initiative Tactic #:                                                                  (if applicable)




                                                                 Project / Capital Request Description




                                               Justification for Project / Capital Request - Potential Risks / Alternatives




Does this request fulfill a commitment? Is this request legally required? (Cite regulation/specifics) How does this request advance key strategies?




                                                                     Other Factors / Assumptions




                                                                 Reason for Project / Capital Request

PRIMARY BENEFIT OF PROJECT (Please check boxes that apply)

Cost Savings                                                                                    Regulation (Be specific, cite reg):

Profit generating                                                                               Mission supported

Quality/Maintenance                                                                             Customer service

Safety                                                                                          Other:




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                                                       OHSU CAPITAL ROI FORM - Total Year 0
                                                                 Sample Project

** NOTE: This form is only to be used if you have multiple years contributing expenditures to Year 0.

                                                              FY 2010                                                                 FY 2015     Total Year 0
                                                             and Prior         FY 2011             FY 2012       FY 2013   FY 2014   and After   Expenditures
              Implementation Costs
   ITG                                                                                                   Input

Capital Expenses
Salaries (w/ Contract Lab./Prof. Svcs, over $100k)                    -               -                  -             -         -          -              -
Contract Labor                                                        -               -                  -             -         -          -              -
Professional Services                                                 -               -                  -             -         -          -              -
Capital Equipment                                                     -               -                  -             -         -          -              -
Building Improvements                                                 -               -                  -             -         -          -              -
Software                                                              -               -                  -             -         -          -              -
Hardware                                                              -               -                  -             -         -          -              -
Freight                                                               -               -                  -             -         -          -              -

Operating Expenses
Salaries & Wages - Operating (under $100k)                            -               -                  -             -         -          -              -
Minor Equipment                                                       -               -                  -             -         -          -              -
Maintenance                                                           -               -                  -             -         -          -              -
Training                                                              -               -                  -             -         -          -              -
Other Expenses (Contingency)                                          -               -                  -             -         -          -              -
   Other Department: _____________________

Capital Expenses
Salaries (w/ Contract Lab./Prof. Svcs, over $100k)                    -               -                  -             -         -          -              -
Contract Labor                                                        -               -                  -             -         -          -              -
Professional Services                                                 -               -                  -             -         -          -              -
Capital Equipment                                                     -               -                  -             -         -          -              -
Building Improvements                                                 -               -                  -             -         -          -              -
Software                                                              -               -                  -             -         -          -              -
Hardware                                                              -               -                  -             -         -          -              -
Freight                                                               -               -                  -             -         -          -              -

Operating Expenses
Salaries & Wages - Operating (under $100k)                            -               -                  -             -         -          -              -
Minor Equipment                                                       -               -                  -             -         -          -              -
Maintenance                                                           -               -                  -             -         -          -              -
Training                                                              -               -                  -             -         -          -              -
Other Expenses (Contingency)                                          -               -                  -             -         -          -              -

Total Project Outlay - Year 0 Total Expenditures                      -               -                  -             -         -          -              -




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Description: Additional Document Requests Template document sample