Form 2 Staffing Profile

OMB No.: 0915-0285. Expiration Date: 10/31/2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 2: STAFFING PROFILE YEAR 1  YEAR 2 	FOR HRSA USE ONLY
	Grant Number		Application Tracking Number
PERSONNEL BY CATEGORY		TOTAL FTEs (a)	AVERAGE ANNUAL SALARY OF POSITION (b)	TOTAL SALARY (a*b)	Total Federal Support Requested
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 Physicians
General Practitioners
Internists
OB/GYNs
Pediatricians
Other Specialty Physicians Please Specify:___________________
Physician Assistants/Nurse Practitioners
Certified Nurse Midwives
Nurses (RNs, LVNs, LPNs)
Pharmacist, Pharmacy Support, Technicians
Other Medical Personnel Please Specify:______________________
Laboratory Personnel (Lab Technicians)
X-Ray Personnel
Clinical Support Staff (Medical Assistants, etc.)
Volunteer Clinical Providers (Medical and Dental)			N/A	N/A	N/A
DENTAL STAFF
Dentists
Dental Hygienists
Dental Assistants, Aides, Technicians
BEHAVIORAL HEALTH STAFF
Behavioral Health Specialists (BH Provider)
Alcohol and Substance Abuse Specialists
Psychiatrists
Psychologists
ENABLING STAFF
Patient Education Specialists (Health Educators)
Case Managers
Outreach (Outreach Staff)
Other Enabling Personnel Please Specify:_____________________
OTHER PROFESSIONAL STAFF (discuss in narrative as appropriate)
OTHER STAFF (discuss in narrative as appropriate)
SALARY TOTAL

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.