Form CMS-10177 CMS SURVEY OF HOSPITALS, SKILLED NURSING FACILITIES, AND

November 28, 2005

CMS SURVEY OF HOSPITALS, SKILLED NURSING FACILITIES,

AND KIDNEY DIALYSIS CENTERS

Survey Questions.

This is a survey of hospitals, skilled nursing facilities (SNFs), and stand-alone kidney dialysis centers (ESRDs) to determine where these institutions purchase their contract labor. The types of contract labor are: (1) accounting and auditing services, (2) engineering services, (3) legal services, and

(4) management consulting services.

1. What is the name of your institution?

2. What is the address of your institution?

3. What is your institution’s Medicare National Provider Identification number?

4. Accounting and auditing services.

Approximately what proportion of your accounting and auditing services is purchased from a firm located outside of your geographic labor market? Include accounting, auditing, actuarial, bookkeeping, payroll processing, other accounting or auditing-related services, and temporary accounting or auditing-related help. Exclude salaries paid to your own employees for these services. Your geographic labor market is the area where most of your employees reside.

i. 0 percent

ii. 1 – 20 percent

iii. 21 – 40 percent

iv. 41 – 60 percent

v. 61 – 80 percent

vi. 81 – 99 percent

vii. 100 percent

5. Engineering services.

Approximately what proportion of your engineering services is purchased from a firm located outside of your geographic labor market? Include architectural, engineering, other architectural or engineering-related services, and temporary architectural or engineering-related help. Exclude salaries paid to your own employees for these services. Your geographic labor market is the area where most of your employees reside.

i. 0 percent

ii. 1 – 20 percent

iii. 21 – 40 percent

iv. 41 – 60 percent

v. 61 – 80 percent

vi. 81 – 99 percent

vii. 100 percent

6. Legal services.

Approximately what proportion of your legal services is purchased from a firm located outside of your geographic labor market? Include legal, legal-related services, and temporary legal-related help. Your geographic labor market is the area where most of your employees reside.

i. 0 percent

ii. 1 – 20 percent

iii. 21 – 40 percent

iv. 41 – 60 percent

v. 61 – 80 percent

vi. 81 – 99 percent

vii. 100 percent

7. Management consulting services.

Approximately what proportion of your management consulting services is purchased from a firm located outside of your geographic labor market? Include management consulting, or management consulting-related services, and temporary management consulting-related help. Your geographic labor market is the area where most of your employees reside.

i. 0 percent

ii. 1 – 20 percent

iii. 21 – 40 percent

iv. 41 – 60 percent

v. 61 – 80 percent

vi. 81 – 99 percent

vii. 100 percent

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