B08_SOL_Att_D_-_MedUtilities.pdf
PDF 182 KB Posted
- Attached to
- DOI Regional Surveys
- Solicitation number
- 140D0426R0121
About this file
This is a template form for collecting community medical services and utility cost data used for federal rent-setting purposes.
The form requires surveyors to document the availability and contact information for medical providers (doctors and dentists) within a survey community. For doctors, surveyors must verify whether a practice is accepting new patients and can schedule appointments; if not available, the community cannot be used for rent-setting. Dentist availability is similarly critical, with non-availability requiring immediate notification to IBC. The form also requires collection of utility rate information for residential customers across multiple service categories: electric, natural gas, water, sewer, garbage collection, propane, and fuel oil. For each utility, contractors can submit data using either Method 1 (fixed consumption costs at standard usage levels such as 500-2,000 KwH for electricity or 50-200 therms for natural gas) or Method 2 (detailed tiered rate structures entered into iQMIS). Method 2 requires specification of summer/year-round and winter rate tiers, base service fees, surcharges, and applicable taxes. Special notations apply where utilities are unavailable (wells for water, septic for sewer, property tax inclusion for garbage). All utility rate sheets must be copied and submitted. The form requires identification of survey region, year, community/state, collector name, and collection date for administrative tracking purposes.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Sol_140D0426R0121_Amd_0001.pdf | ||
| B09_SA_Att_F-Questions_and_Answer_Form_Final_0001.pdf | ||
| Sol_140D0426R0121.pdf | ||
| B08_SOL_Att_C_-_OS-2001.pdf | ||
| B08_SOL_Att_B_-_OS-2000.pdf | ||
| B08_SOL_140D0426R0121_cont_pages.pdf | ||
| B08_SOL_Att_E_-_HousingData.pdf | ||
| B08_SOL_Att_F_-_Questions_and_Answer_Form.xlsx | XLSX spreadsheet | |
| B08_SOL_Att_G_-_Price_Proposal_Excel_Spreadsheet.xlsx | XLSX spreadsheet | |
| B08_SOL_Att_A_-_Communities.xlsx | XLSX spreadsheet |
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Text version
ATTACHMENT D COMMUNITY MEDICAL/UTILITIES SURVEY
Community Medical and Utilities Survey
Survey Region________ Survey Year____________
Survey Community/State______________________________
Collected By_____________________________ Date Collected_______________________
Doctor Office/Clinic/Business Name___________________________________________________________
Not Available, Not Accepting New Patients or No Appointment can be made with a Doctor (If not, survey another provider. If no other providers available, contact IBC immediately because community cannot be used for rent-setting.)
Accepting New Patients and Appointment can be made with Doctor
Doctor Name(s)______________________________________________________________________ Address____________________________________________________________________________ Phone/Web__________________________________________________________________________ Comments/Hours_____________________________________________________________________
Dentist Office/Clinic/Business Name__________________________________________________________
Not Available (Contact IBC immediately because community cannot be used for rent-setting)
Accepting New Patients (If not, survey another dentist in the community)
Dentist Name(s)______________________________________________________________________ Address____________________________________________________________________________ Phone/Web__________________________________________________________________________ Comments/Hours____________________________________________________________________
Electric Utility Company Name_______________________________________________________________ Copy of rate sheets required Phone/Web__________________________________________________________________________ Comments/Contact Name_______________________________________________________________ Method 1: Cost to Residential Customers: (average summer/winter rates if applicable; include all taxes) 500 KwH____________ 1,000 KwH___________ 1,500 KwH___________ 2,000 KwH___________
Method 2: Contractor can enter into iQMIS the following cost components:
Summer/Year-Round (_____Months) Winter (______Months)
Tier 1 ______ KwH @ Tier 1 Rate ___________ Tier 1 ______ KwH @ Tier 1 Rate ___________
Tier 2 ______ KwH @ Tier 2 Rate ___________ Tier 2 ______ KwH @ Tier 2 Rate ___________ Tier 3 ______ KwH @ Tier 3 Rate ___________ Tier 3 ______ KwH @ Tier 3 Rate ___________ Tier 4 ______ KwH @ Tier 4 Rate ___________ Tier 4 ______ KwH @ Tier 4 Rate ___________ All Over Tier 4 @ Tier 5 Rate ___________ All Over Tier 4 @ Tier 5 Rate ___________
Other Charges (Year Round):
Base Rate/Service Fee/Minimum Fee/Flat Rate Per Month ________________ Additional/Surcharges Per KwH _______________________________ _________________ Additional/Surcharges Per KwH _______________________________ _________________ Additional/Surcharges Per KwH _______________________________ _________________ Taxes Per KwH_____________________ Taxes Percent ________________%
Natural Gas Utility Company Name ____________________________________ Not Available
Phone/Web______________________________________________ Comments/ Contact Name_______________________________________________________________ Method 1: Cost to Residential Customers: (average summer/winter rates if applicable; include all taxes) 50 Therms____________ 100 Therms___________ 150 Therms___________ 200 Therms___________ (1 Therm = 1 CCF = 100 CF. 10 Therms = 10 CCF = 1,000 CF = 1 MCF) Method 2: Contractor can enter into iQMIS the following cost components:
Natural Gas Units and Rates are published by: Therm CCF MCF
Summer/Year-Round (_______Months) Winter (________Months) Tier 1 ______ Units @ Tier 1 Rate ___________ Tier 1 ______ Units @ Tier 1 Rate ___________ Tier 2 ______ Units @ Tier 2 Rate ___________ Tier 2 ______ Units @ Tier 2 Rate ___________ Tier 3 ______ Units @ Tier 3 Rate ___________ Tier 3 ______ Units @ Tier 4 Rate ___________ Tier 4 ______ Units @ Tier 4 Rate ___________ Tier 4 ______ Units @ Tier 5 Rate ___________ All Over Tier 4 Units @ Tier 5 Rate __________ All Over Tier 4 Units @ Tier 5 Rate __________
Other Charges (Year-Round):
Base Rate/Service Fee/Minimum Fee Per Month $___________ (optional -- includes ____________Units) Additional Flat Rate Service Fee Per Month $______________ Additional/Surcharges Per Unit________________________ __________ Additional/Surcharges Per Unit________________________ __________ Additional/Surcharges Per Unit________________________ __________ Taxes Per Unit_____________________ Taxes/Additional Percent ____________%
Water Utility Company Name _______________________________________ Not Available (Wells)
Copy of rate sheets required Phone, Web____________________________________________ Comments/ Contact Name_______________________________________________________________ Method 1: Cost to Residential Customers: (average summer/winter rates if applicable; include all taxes) 3,000 gals.____________ 5,000 gals.___________ 7,500 gals.___________ 10,000 gals.___________ (1 cu ft = 7.48 gals. 100 cu ft = 748 gals. 100 cu ft = 1 CCF) Method 2: Contractor can enter into iQMIS the following cost components:
Water Units and Rates are published by: Gallon CF CCF
Summer/Year-Round (_______Months) Winter (________Months) Tier 1 ______ Units @ Tier 1 Rate ___________ Tier 1 ______ Units @ Tier 1 Rate ___________ Tier 2 ______ Units @ Tier 2 Rate ___________ Tier 2 ______ Units @ Tier 2 Rate ___________ Tier 3 ______ Units @ Tier 3 Rate ___________ Tier 3 ______ Units @ Tier 4 Rate ___________ Tier 4 ______ Units @ Tier 4 Rate ___________ Tier 4 ______ Units @ Tier 5 Rate ___________ All Over Tier 4 Units @ Tier 5 Rate __________ All Over Tier 4 Units @ Tier 5 Rate __________
Other Charges (Year-Round):
Base Rate/Service Fee/Minimum Fee Per Month $___________ (optional -- includes ____________Units) Additional Flat Rate Service Fee Per Month $______________ Additional Surcharges Per Unit___________________ _________ Additional Surcharges Per Unit___________________ _________ Additional Surcharges Per Unit___________________ _________ Taxes Per Unit_____________________ Taxes/Additional Percent ____________%
Sewer Utility Company Name _______________________________________ Not Available (Septic)
Phone, Web____________________________________________ Comments/ Contact Name_______________________________________________________________ Method 1: Cost to Residential Customers: (average summer/winter rates if applicable; include all taxes) 3,000 gals.____________ 5,000 gals.___________ 7,500 gals.___________ 10,000 gals.___________ (1 cu ft = 7.48 gals. 100 cu ft = 748 gals. 100 cu ft = 1 CCF) Method 2: Contractor can enter into iQMIS the following cost components:
Sewer Units and Rates are published by: Gallon CF CCF
Summer/Year-Round (_______Months) Winter (________Months) Tier 1 ______ Units @ Tier 1 Rate ___________ Tier 1 ______ Units @ Tier 1 Rate ___________
Tier 2 ______ Units @ Tier 2 Rate ___________ Tier 2 ______ Units @ Tier 2 Rate ___________ Tier 3 ______ Units @ Tier 3 Rate ___________ Tier 3 ______ Units @ Tier 4 Rate ___________ Tier 4 ______ Units @ Tier 4 Rate ___________ Tier 4 ______ Units @ Tier 5 Rate ___________ All Over Tier 4 Units @ Tier 5 Rate __________ All Over Tier 4 Units @ Tier 5 Rate __________
Other Charges (Year-Round):
Base Rate/Service Fee/Minimum Fee Per Month $___________ (optional -- includes ____________Units) Additional Flat Rate Service Fee Per Month $______________ Additional Surcharges Per Unit___________________ _________ Additional Surcharges Per Unit___________________ _________ Additional Surcharges Per Unit___________________ _________ Taxes Per Unit_____________________ (taxes usually do not apply to sewer charges) Taxes/Additional Percent ____________% (taxes usually do not apply to sewer charges)
Garbage Collection Company Name___________________________________ Not Available
Phone, Web______________________________ Incl. in Property Taxes
Contact Name/Comments_______________________________________________________________ Rate Per Month $____________________ include recycling, yard debris, mosquito control, and other charges that are typically included in the monthly garbage fee. Assume 2 cans per week or one 65 gal. can
Propane Company #1 Name ____________________________________ Not Available
Contact Name, Phone, Web________________________________________________ Rate Per Gal. $________________ (include taxes)
Propane Company #2 Name (if available) _____________________________________________
Rate Per Gal. $________________ (include taxes)
Fuel Oil Company #1 Name____________________________________ Not Available
Rate Per Gal. $________________ (include taxes)
Fuel Oil Company #2 Name (if available) ____________________________________ Contact Name, Phone, Web_______________________________________________ Rate Per Gal. $_______________ (include taxes)
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