OMB No.: 0915-0285. Expiration Date: 08/31/2010
DEPARTMENT OF HEALTH AND
HUMAN SERVICES |
FOR HRSA USE ONLY |
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Grant Number |
Application Tracking Number |
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PERSONNEL BY CATEGORY |
TOTAL FTEs |
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TOTAL SALARY |
ADMINISTRATION |
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Executive Director / CEO |
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Finance Director (Fiscal Officer) / CFO |
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Chief Operating Officer / COO |
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Chief Information Officer / CIO |
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Administrative Support Staff |
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MEDICAL STAFF |
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Medical/Clinical Director |
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Family Physicians |
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General Practitioners |
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Internists |
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OB/GYNs |
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Pediatricians |
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Other Specialty Physicians: Please Specify:___________________ |
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Physician Assistants/Nurse Practitioners |
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Certified Nurse Midwives |
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Nurses (RNs, LVNs, LPNs) |
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Pharmacist, Pharmacy Support, Technicians |
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Other Medical Personnel: Please Specify:______________________ |
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Laboratory Personnel (Lab Technicians) |
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X-ray Personnel |
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Clinical Support Staff (Medical Assistants, etc) |
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Volunteer Clinical Providers (Medical and Dental) |
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N/A |
N/A |
DENTAL STAFF |
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Dentists |
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Dental Hygienists |
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Dental Assistants, Aides, Technicians |
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MENTAL HEALTH STAFF |
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Mental Health Specialists (MH Provider) |
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Alcohol and Substance Abuse Specialists |
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Psychiatrists |
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Psychologists |
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ENABLING STAFF |
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Patient Education Specialist (Health Educator) |
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Case Managers |
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Outreach (Outreach Staff) |
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Other Enabling |
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OTHER PROFESSIONAL STAFF (discuss in narrative as appropriate) |
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OTHER STAFF |
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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 currently 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 1 hour 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.
| File Type | application/msword |
| File Title | OMB No |
| Author | Kinny Padh |
| Last Modified By | Hrsa |
| File Modified | 2010-06-11 |
| File Created | 2010-06-11 |