Form 16 Form 2 - clean

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

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 portion allocated 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) 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
Information Technology Staff		[_] Yes [_] No
Patient Services Support		[_] 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 objective review committee panels 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 (42 U.S.C. 254b). 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 14N136B, Rockville, Maryland, 20857 or [email protected].