Form 0285 staff profile 0285 staff profile 0285 staff profile

OMB No. 0915-0285

Expiration Date:

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-0285. Public reporting burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

PROPOSED STAFF PROFILE

PERSONNEL BY CATEGORY	TOTAL FTEs { a }	ANNUAL SALARY OF POSITION { b }	TOTAL SALARY { a * b }
ADMINISTRATION
Executive Director / CEO
Finance Director (Fiscal Officer) / CFO
Chief Operating Officer/ COO
Chief Information Officer/ CIO
Administrative Support Staff
MEDICAL STAFF
Medical/Clinical Director
Family Practitioners
General Practitioners
Internists
OB/GYNs
Pediatricians
Other Specialty Physicians - Please list:___________________
Physician Assistants/Nurse Practitioners, Certified Nurse Midwives
Nurses (RNs, LVNs, LPNs)
Pharmacist, Pharmacy Support, Technicians
Other Medical Personnel - Please list:______________________
Laboratory Personnel (Lab Technicians)
X-ray Personnel
Clinical Support Staff (Medical Assistants, etc)
Volunteer Clinical Providers (Medical and Dental)		$0.00	NA
DENTAL STAFF
Dentists
Dental Hygienists
Dental Assistants, Aides, Technicians
MENTAL HEALTH STAFF
Mental Health Specialists (MH Provider)
Alcohol and Substance Abuse Specialists
Psychiatrists
Psychologists
ENABLING STAFF
Patient Education Specialist (Health Educator)
Case Managers
Outreach (Outreach Staff)
Other Enabling
OTHER PROFESSIONAL STAFF
OTHER STAFF

2