Attachment C - DRAFT CPRMP VA1391-C - BLANK.pdf

1. ADMINISTRATION

VA

FY 20XX CONSTRUCTION PROJECT DATA

2. DATA AS OF

Month DD, YYYY

3. VERSION #

X

4. LOCATION

Alameda, CA

5. PROJECT TITLE

Community Based Outpatient Clinic

6. TOTAL ESTIMATED COST

($000)

$XXX,XXX

7. PRIORITY SCORE

FY ASSIGNED

0.XXXX

FY 20XX

VA 1391-C DRAFT 02/07/2024 1

VA 1391-C Summary Page

A. Construction Project Description

A1. PROJECT DESCRIPTION

[Enter Project Description]

B. Summary Project Information

B1. BUDGET AUTHORITY ($000)

Prior Years BY – 2 BY – 1 BY Future Year(s) Total Estimated Cost

FY 20XX Budget XXX,XXX XXX,XXX XXX,XXX XXX,XXX XXX,XXX XXX,XXX FY 20XX Budget XXX,XXX XXX,XXX XXX,XXX XXX,XXX XXX,XXX XXX,XXX

C2. PROJECT COST AND SCHEDULE DATA BY PHASE

Budget

Request Year Phase

Original Request ($000)

Updated Request ($000)

Original Estimated Completion Date

Updated Estimated Completed Date

20XX Design XX,XXX XX,XXX

Detailed Schedule Information Provided in Section #21 Below

20XX

Phase I – Site Work, Off-Site Utilities, and Wetlands Mitigation XX,XXX XX,XXX

20XX

Phase I – Columbarium, Site Work, Off-Site Utilities, and Wetlands Mitigation XX,XXX XX,XXX

20XX

Phase II – Community Based Outpatient Clinic XX,XXX XX,XXX

20XX

Phase III – Conservation Management Office, Landscaping, Parking, and Completion of Columbarium XX,XXX XX,XXX

Total Estimated Cost $ XXX,XXX $ XXX,XXX Note: Full VA 1391-C Summary Page included as Attachment I of the VA 1391 Package

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VA 1391-C DRAFT 02/07/2024 2

C. Supporting Budget Justification Data

C1. DEMOGRAPHIC DATA*

Actual

Projected

Projected

Projected

Change (2021 – 2041)

Veteran Population XXX,XXX XXX,XXX XXX,XXX XXX,XXX -XX.X% Enrollees XXX,XXX XXX,XXX XXX,XXX XXX,XXX -XX.X% 1Data reflects the VISN XX, North Valley Market.

2Data for national cemetery only.

C2. WORKLOAD*

Actual

Projected

Projected

Projected Change

(2021 – 2041) Ambulatory Procedures1 XXX XXX XXX XXX XX.X% Ambulatory Services1 XXX XXX XXX XXX XX.X% Mental Health Stops1 XXX XXX XXX XXX XX.X% Mental Health Services1 XXX XXX XXX XXX XX.X% Acute Inpatient Beds1 XXX XXX XXX XXX XX.X% Acute Mental Health Beds1 XXX XXX XXX XXX XX.X% Annual Interments2

Planned Opening September 2022Cumulative Gravesites2

Cumulative Interments2

1Data reflects the VISN XX, North Valley Market, and excludes Pharmacy and Laboratory and Pathology stops.

2Data for national cemetery only.

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C3. WORK IN PROGRESS CHART

C4. JUSTIFICATION FOR CHANGES

Scope Changes:

[Enter Justification for Scope Changes if applicable]

Budget Changes:

[Enter Justification for Budget Changes if applicable]

Schedule Changes:

[Enter Justification for Schedule Changes if applicable]

C5. PROJECT JUSTIFICATION

[Enter Project Justification]

C6. ANALYSIS OF BENEFITS/IMPACT IF NOT FUNDED

[Enter Analysis of Benefits/Impact if not Funded]

C7. SCHEDULE

ITEM DATE

Phase I – Wetlands Design Start XX/XX/XXXX

0.XXXX

FY 20XX

VA 1391-C DRAFT 02/07/2024 4

Date 35% Complete XX/XX/XXXX Award Construction Documents XX/XX/XXXX Design Complete XX/XX/XXXX Award Construction Contract XX/XX/XXXX Date Used for Escalation XX/XX/XXXX

Phase II – Site Work and Columbarium Design Start XX/XX/XXXX Date 35% Complete XX/XX/XXXX Award Construction Documents XX/XX/XXXX Design Complete XX/XX/XXXX Award Construction Contract XX/XX/XXXX Construction Completion XX/XX/XXXX

Phase III – Utilities Design Start XX/XX/XXXX Date 35% Complete XX/XX/XXXX Award Construction Documents XX/XX/XXXX Design Complete XX/XX/XXXX Award Construction Contract XX/XX/XXXX Construction Completion XX/XX/XXXX

C8. DESIGN CONTRACT TYPE

Firm, Fixed Price

C9. ANALYSIS OF ALTERNATIVES

Status Quo:

[Enter Status Quo description]

Alternative 1: New Construction (Preferred Alternative) [Enter Alternative 1 description]

Alternative 2: Renovation [Enter Alternative 2 description]

Alternative 3: Lease [Enter Alternative 3 description]

Alternative 4: Contract Out [Enter Alternative 4 description]

Alternative 5: Acquisition of an Existing Facility through Purchase [Enter Alternative 5 description]

Alternative 6: Collaboration with DoD for a Joint Project [Enter Alternative 6 description]

C10. ANALYSIS OF ALTERNATIVES – 30-YEAR COSTS IN DISCOUNTED DOLLARS ($000)

0.XXXX

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VA 1391-C DRAFT 02/07/2024 5

Acquisition* Ancillary Services**

Equipment and Other Items Total Life Cycle Total # of FTEE Net New FTEE

Status Quo 0 $XXX,XXX $XXX,XXX $XXX,XXX XXX N/A New Construction $XXX,XXX $XXX,XXX $XXX,XXX $XXX,XXX XXX XX

Renovation N/A N/A N/A N/A N/A N/A Lease $XXX,XXX $XXX,XXX $XXX,XXX $XXX,XXX XXX XX Contract Out $XXX,XXX $XXX,XXX $XXX,XXX $XXX,XXX XXX (XXX) Acquire an Existing Facility N/A N/A N/A N/A N/A N/A

VA/DOD

Collaboration N/A N/A N/A N/A N/A N/A

Other (if applicable) N/A N/A N/A N/A N/A N/A

*This is the total estimated cost for construction/renovation projects or build-out (special purpose renovations) for leases, in discounted dollars.

**This is defined as operating expenses and supplies (recurring costs from the cost-effectiveness analysis template)

C11. ADDITIONAL INFORMATION

N/A

D. Cost Information

D1. DESIGN COSTS ($000)

ITEM COST

Preparation of Plans & Specifications All Other Design Costs Subtotal, Design Costs

D2. CONSTRUCTION COSTS ($000)

ITEM QUANTITY UM UNIT COST COST

Primary Facilities New Construction Alterations Building Demolition Subtotal, Primary Facilities

Supporting Facilities Parking Structure Total Other Costs (Utilities, etc.)

Subtotal, Supporting Facilities

XXX,XXX

X X

XXX

SF

SF

SF

Spaces

XXX

X X

X

XXX,XXX

X X

XXX,XXX

Included Above

XXX,XXX

XXX,XXX

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FY 20XX

VA 1391-C DRAFT 02/07/2024 6

Construction Costs (Primary plus Supporting Facilities) Escalation Subtotal, Estimated Contract Cost

Pre-Design Development Allowance Construction Contingency Impact Costs Construction Management Site Acquisition Utility Agreements Subtotal, Construction Costs

XXX,XXX

XXX,XXX

XXX,XXX

X

XXX,XXX

X X X X

XXX,XXX

D3. TOTAL ESTIMATED COST ($000)

Design Costs (Section 15) plus Construction Costs (Section 16) XXX,XXX

D4. COST OF ITEMS PROCURED THROUGH OTHER APPROPRIATIONS ($)

APPROPRIATION ITEM QUANTITY UNIT COST COST

N/A

D5. PROJECTED OPERATING COSTS IN DISCOUNTED DOLLARS ($000)

ITEM CUMULATIVE PROJECT COSTS

Start Year

20XX*

Start Year + 5

20XX

Start Year + 10

20XX

Start Year + 20

20XX

Year 30

20XX*

Non-Recurring Costs

– Construction Activities XXX,XXX XXX,XXX XXX,XXX XXX,XXX XXX,XXX

– Equipment 0 XXX,XXX XXX,XXX XXX,XXX XXX,XXX

Recurring Costs

– Services 0 XXX,XXX XXX,XXX XXX,XXX XXX,XXX

– Support Services 0 XXX,XXX XXX,XXX XXX,XXX XXX,XXX

– Supplies 0 XXX,XXX XXX,XXX XXX,XXX XXX,XXX

– Personnel & Compensation 0 XXX,XXX XXX,XXX XXX,XXX XXX,XXX

Subtotal Recurring Costs 0 XXX,XXX XXX,XXX XXX,XXX XXX,XXX

TOTAL OPERATING COSTS XXX,XXX XXX,XXX XXX,XXX XXX,XXX XXX,XXX

FTEE XXX XXX XXX XXX XXX

*Budget fiscal year is 20XX. CEA includes 30 years from the budget fiscal year.

D6. ANNUAL OPERATING COSTS IN CURRENT DOLLARS ($000)

FTE Project Costs FTE Present Facility

Non-recurring costs

- Activation XXX,XXX N/A

- One-time non-recurring XXX,XXX N/A

Subtotal Non-recurring XXX,XXX N/A Recurring Costs1

- Ancillary Services XXX,XXX XXX,XXX

- Personnel Services (FTE/Costs) XX XXX,XXX X,XXX XXX,XXX

- Other Recurring N/A N/A

Subtotal Recurring XXX,XXX XXX,XXX

TOTAL OPERATING COSTS XXX,XXX XXX,XXX

1Operating costs recur on an annual basis for resources (including staff) necessary to support services to be provided from th e space being built or remodeled.

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2Incremental operating costs are net of present facility. These are not indicative of the total operating costs for the project at completion.

D7. OTHER COSTS

ITEM COST

N/A

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E. Capital Program Requirements Management Process (CPRMP) This section will be completed only if a CPRMP submission is necessary due to requested changes after SCIP Approval.

E1. SPACE CHANGES(BGSF) IN SUPPORT OF CPRMP REQUEST

Space Types – Enter Current and Proposed Changes by SCIP Baseline Latest Externally Communicated

Baseline Project Total Post-Requested Changes

Inpatient Mental Health CLC/Hospice Administration Research Support/ Infrastructure Ancillary/ Diagnostic Mental Health Primary Care Specialty Care Acute Inpatient Medicine & Surgery Acute Special Programs Common/Swing/ Construction If Change in Space, provide justification for the change. Attach additional supporting documents if needed. VHA must provide demographic information for all proposed changes.

E2. UTILIZATION CHANGES IN SUPPORT OF CPRMP REQUEST

Utilization Categories SCIP Baseline Latest Externally Communicated

Baseline Project Total Post-Requested Changes

Inpatient Medicine (BDOC) Inpatient Mental Health

(BDOC)

Dental Clinic (Procedures) Laboratory and Pathology (Clinic Stops) Medical & Other Non-Surg Specialties (Clinic Stops) Mental Health Programs (Clinic Stops) Primary Care-Geriatrics- Urgent Care (Clinic Stops) Surgical Specialties (Clinic Stops) Inpatient Residential Rehab Mental Health Programs

(BDOC)

Long Term Care (LTC)Non- Institutional (Clinic Stops) Blind Rehab (BDOC) Inpatient LTC (BDOC) Spinal Cord Injury (BDOC) If Change in Utilization, provide justification for the change. Attach additional supporting documents if needed. VHA must provide demographic information for all proposed changes.

E3. BED COUNT CHANGES (INPATIENT PROJECTS) IN SUPPORT OF CPRMP REQUEST

Bed Categories SCIP Baseline Latest Externally Project Total Post-Requested Changes

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Communicated Baseline Inpatient Medical Inpatient Surgical Acute Inpatient Mental Health

Blind Rehab CLC/Hospice Residential Rehab Mental Health Spinal Cord Polytrauma Hotel If Change in Inpatient Beds, provide justification for the change. Attach additional supporting documents if needed. VHA must provide demographic and workload information for all proposed changes.

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F. Attachments F1. Implementation Planning Output

I. Service Delivery Plan II. Gap Mitigation Plan

III. Functional Program IV. Project Definition

F2. Attachments for Post-SCIP/Budget Submission and Execution Planning Information I. Acquisition Plan II. Pre-Procurement Scoring Report