16E Form 2 - edits

The Health Center Program Application Forms

Form 2 - edits

Form 2: Staffing Profile

OMB: 0915-0285

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OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

Form 2: Staffing Profile

Note: The health center must directly employ its Project Director/CEO. Allocate staff time by function among the positions listed. An individual’s full-time equivalent (FTE) should not be duplicated across positions. For example, a provider serving as a part-time family physician and a part-time Clinical Director should be listed in each respective category, with the FTE percentage p ortionallocated to each position (e.g., Clinical Director 0.3 (30%) FTE and family physician 0.7 (70%) FTE). Do not exceed 1.0 FTE for any individual. Refer to the most recent UDS manual (https://bphc.hrsa.gov/datareporting/reporting HYPERLINK "https://bphc.hrsa.gov/datareporting/reporting"  HYPERLINK "" ) for position descriptions.

Key Management Staff/Administration

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/Agreement FTEs

Project Director/Chief Executive Officer (CEO)


[_] Yes [_] No

Finance Director/Chief Financial Officer (CFO)


[_] Yes [_] No

Chief Operating Officer (COO)


[_] Yes [_] No

Chief Information Officer (CIO)


[_] Yes [_] No

Clinical Director/Chief Medical Officer (CMO)


[_] Yes [_] No

Administrative Support Staff


[_] Yes [_] No

Facility and Non-Clinical Support Staff

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/ Agreement FTEs

Fiscal and Billing Staff


[_] Yes [_] No

IT Staff


[_] Yes [_] No

Facility Staff


[_] Yes [_] No

Patient Support Staff


[_] Yes [_] No

Physicians

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/ Agreement FTEs

Family Physicians


[_] Yes [_] No

General Practitioners


[_] Yes [_] No

Internists


[_] Yes [_] No

Obstetrician/Gynecologists


[_] Yes [_] No

Pediatricians


[_] Yes [_] No



Licensed Medical Residents


[_] Yes [_] No

Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/ Agreement FTEs

Nurse Practitioners


[_] Yes [_] No

Physician Assistants


[_] Yes [_] No

Certified Nurse Midwives


[_] Yes [_] No

Medical

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/ Agreement FTEs

Nurses


[_] Yes [_] No

Other Medical Personnel

(e.g. Medical Assistants, Nurse Aides)

Please specify: (maximum 40 characters) ______________


[_] Yes [_] No

Laboratory Personnel


[_] Yes [_] No

X-Ray Personnel


[_] Yes [_] No

Dental Services

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/ Agreement FTEs

Dentists


[_] Yes [_] No

Dental Hygienists


[_] Yes [_] No

Dental Therapists


[_] Yes [_] No

Other Dental Personnel

Please Specify: (maximum 40 characters) ___________


[_] Yes [_] No

Mental Health

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/ Agreement FTEs

Psychiatrists


[_] Yes [_] No

Physicians (other than psychiatrists)


[_] Yes [_] No

Nurse Practitioners


[_] Yes [_] No

Physician Assistants


[_] Yes [_] No

Certified Nurse Midwives


[_] Yes [_] No

Nurses- psychiatric, mental health


[_] Yes [_] No

Nurse Counselors


[_] Yes [_] No

Licensed Clinical Psychologists


[_] Yes [_] No

Licensed Clinical Social Workers


[_] Yes [_] No

Family Therapists



Unlicensed Mental Health Providers, including trainees and certified staff



Other Licensed Mental Health Providers

Please Specify: (maximum 40 characters) ___________


[_] Yes [_] No

Other Mental Health Staff

Please Specify: (maximum 40 characters) ___________


[_] Yes [_] No

Substance Use Disorder



Psychiatrists


[_] Yes [_] No

Physicians (other than psychiatrists)


[_] Yes [_] No

Nurse Practitioners


[_] Yes [_] No

Physician Assistants


[_] Yes [_] No

Certified Nurse Midwives


[_] Yes [_] No

Nurse Counselors


[_] Yes [_] No

Licensed Clinical Psychologists


[_] Yes [_] No

Licensed Clinical Social Workers


[_] Yes [_] No

Family Therapists


[_] Yes [_] No

Alcohol and Drug Abuse Counselors


[_] Yes [_] No

Other Licensed Mental Health Providers


[_] Yes [_] No

Professional Services

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/ Agreement FTEs

Other Professional Health Services Staff

Please Specify: (maximum 40 characters) ___________


[_] Yes [_] No

Vision Services

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/ Agreement FTEs

Ophthalmologists


[_] Yes [_] No

Optometrists


[_] Yes [_] No

Other Vision Care Staff

Please Specify: (maximum 40 characters) ___________


[_] Yes [_] No

Pharmacy Personnel

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/ Agreement FTEs

Pharmacy Personnel


[_] Yes [_] No

Enabling Services

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/ Agreement FTEs

Case Managers


[_] Yes [_] No

Patient/Community Education Specialists


[_] Yes [_] No

Patient Advocates


[_] Yes [_] No

Outreach Workers


[_] Yes [_] No

Transportation Staff


[_] Yes [_] No

Eligibility Assistance Workers


[_] Yes [_] No

Interpretation Staff


[_] Yes [_] No

Community Health Workers


[_] Yes [_] No

Other Enabling Services Staff

Please Specify: (maximum 40 characters) ___________


[_] Yes [_] No

Other Programs and Services

Staffing Positions

by Major Service Category

Direct Hire FTEs

Contract/ Agreement FTEs

Quality Improvement Staff


[_] Yes [_] No

Other Programs and Services Staff

Please Specify: (maximum 40 characters) ___________


[_] Yes [_] No

Total FTEs

Totals

Direct Hire FTEs

Contract/ Agreement FTEs

Totals

will auto-calculate in EHB

N/A


Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (objective review committee panels42 U.S.C. 254b HYPERLINK "http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim" ). Public reporting burden for this collection of information 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 14N136B, Rockville, Maryland, 20857 or to average 1 houris estimated [email protected] HYPERLINK "[email protected]" .


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleForm 2
AuthorBeth Hartmayer
File Modified0000-00-00
File Created2021-01-14

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