Form ETA 9222 ETA 9222 Health and Wellness Center Annual Program Description

U.S. Department of Labor Employment and Training Administration Office of Job Corps

ETA Form 9222 OMB Control No. 1205-0219 Expiration Date: 05/31/2025

Health and Wellness Annual Program Description [YYYY]

For any questions, please email Leah Pan. Please complete prior to August 15, [YYYY].

Contact Information and Staffing
1. Region*
2. Center*
3. Person completing APD name and Title*	Enter information here
4. Health and Wellness Director or designee email*	Enter information here
5. Do you currently have a Health and Wellness Director?*	☐ Yes ☐ No

Health and Wellness Director
6. Health and Wellness Director (HWD) compensation type *		☐ Salary ☐ Contract ☐ Subcontractor ☐ Fee-for-service
7. HWD total hours per week/ hourly rate *
	HWM Total Hours per week	Enter information here
	HWM hourly rate	Enter information here

Nurses
8. Do you have a second RN (not the HWD)?*		☐ Yes ☐ No
9. Staff Nurses compensation type (Check all that apply)*		☐ Salary ☐ Contract ☐ Subcontractor ☐ Fee-for-service
10. Staff Nurses total hours per week/ hourly rate*
	Staff Nurses Total Hours per week	Enter information here
	Staff Nurses hourly rate	Enter information here

Center Physician
11. Do you have a second CP/NP/PA?*		☐ Yes ☐ No
12. CP/NP/PA provider type (Check all that apply)*		☐ Center Physician ☐ NP ☐ PA
13. CP/NP/PA compensation type (Check all that apply)*		☐ Salary ☐ Contract ☐ Subcontractor ☐ Fee-for-service
14. CP/NP/PA total hours per week/ hourly rate *
	CP/NP/PA Total Hours per week
	CP/NP/PA hourly rate
15. CP/NP/PA provider days on center*		☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday
16. Do you currently have a Center Mental Health Consultant?*		☐ Yes ☐ No

Center Mental Health Consultant (CMHC)
17. CMHCs license type (Check all that apply)*		☐ PhD/PsyD ☐ LCSW ☐ LPC/LMHC ☐ Other (please specify): Specify here
18. CMHC compensation type (Check all that apply)*		☐ Salary ☐ Contract ☐ Subcontractor ☐ Fee-for-service
19. CMHC total hours per week/ hourly rate*
	CMHC Total Hours per week	Enter information here
	CMHC hourly rate	Enter information here
20. CMHC provider days on center*		☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday
21. Do you currently have a TEAP Specialist?*		☐ Yes ☐ No

TEAP Specialist
22. TEAP Specialist license type (Check all that apply)*		☐ LADC ☐ CAADC ☐CADC ☐ CASAC ☐ CRADC ☐ CSAC ☐ LAC ☐ LADAC ☐ SUDPC ☐ Other (please specify): Specify here
23. TEAP Specialist compensation type (Check all that apply)*		☐ Salary ☐ Contract ☐ Subcontractor ☐ Fee-for-service
24. TEAP Specialist total hours per week/ hourly rate *
	CMHC Total Hours per week	Enter information here
	CMHC hourly rate	Enter information here
25. TEAP Specialist provider days on center*		☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday
26. Do you currently have a Dentist?*		☐ Yes ☐ No

Dentist
27. Dentist compensation type (Check all that apply)		☐ Salary ☐ Contract ☐ Subcontractor ☐ Fee-for-service
28. Dentist total hours per week/ hourly rate *
	Dentist Total Hours per week	Enter information here
	Dentist hourly rate	Enter information here
29. Dentist days on center*		☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday
30. Do you currently have a Dentist Hygienist?*		☐ Yes ☐ No

Dentist Hygienist
31. Dentist Hygienist compensation type (Check all that apply)*		☐ Salary ☐ Contract ☐ Subcontractor ☐ Fee-for-service
32. Dentist Hygienist total hours per week/ hourly rate *
	Dentist Hygienist Total Hours per week	Enter information here
	Dentist Hygienist hourly rate	Enter information here
33. Dentist Hygienist days on center*		☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday
34. Do you currently have a Dentist Assistant?*		☐ Yes ☐ No

Dentist Assistant
35. Dentist Assistant compensation type (Check all that apply)*		☐ Salary ☐ Contract ☐ Subcontractor ☐ Fee-for-service
36. Dentist Assistant total hours per week/ hourly rate *
	Dentist Assistant Total Hours per week	Enter information here
	Dentist Assistant hourly rate	Enter information here
37. Dentist Assistant days on center*		☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday
38. Do you currently have a Clerk?*		☐ Yes ☐ No

Clerk
39. Clerk compensation type (Check all that apply)*		☐ Salary ☐ Contract ☐ Subcontractor ☐ Fee-for-service
40. Clerk total hours per week/ hourly rate *
	Clerk Total Hours per week	Enter information here
	Clerk hourly rate	Enter information here
41. Clerk days on center*		☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday

Optometrist
42. Optometrist*
	Name	Enter information here
	Address	Enter information here
	Cost of Exam	Enter information here
	Cost of glasses/lenses	Enter information here

Medical Unit
43. Medical Unit*
	Health and Wellness Clinic hours	Enter information here
	Emergency care hospital details: Name	Enter information here
	Emergency care hospital: Address	Enter information here
	Emergency care hospital: Distance from center	Enter information here
44. Medical Unit: In patient care*
	In patient care: Name	Enter information here
	In patient care: Address	Enter information here
	In patient care: Distance from center	Enter information here
	In patient care: Physician have admitting privileges?	☐ Yes ☐ No
	In patient care: Written agreement with the facility?	☐ Yes ☐ No
45. List all professionals on-call after hours when the HWC is closed (Check all that apply)*		☐ HWD ☐ Nurse ☐ CP/NP/PA ☐ CMHC ☐ TEAP Specialist ☐ Other (please specify): Specify here

Dental Unit
46. Dental operations		☐ On-center ☐ Off-center
47. Off-center dental services (If applicable)
	Name	Enter information here
	Address	Enter information here

Dental Unit
48. Mental Health Unit*
	Average number of applicant files reviewed per week
	Average number of student appointments for intake/assessment per week
	Average number of student appointments for short-term treatment per week (case load)
	List local behavioral health agencies, community programs, or networks available for long-term mental health treatment
49. Mental Health Unit (Please complete if different from Medical Unit) *
	Health Emergency care hospital details – Name
	Mental Health Emergency care hospital – Address
	Mental Health Emergency care hospital – Distance from center Mental
	Health In patient care: Name
	Mental Health In patient care – Address
	Mental Health In patient care – Distance from center
	Mental Health In patient care – Written agreement with the facility? Y/N
50. Is a mobile crisis unit available?*

TEAP/TUPP
51. Number of intervention group sessions*
52. Who conducts urine drug screen? (Check all that apply)*	☐ TEAP Specialist ☐ Nurses ☐ Other (please specify)
53. Who conducts alcohol tests? (Check all that apply)*	☐ TEAP Specialist ☐ Security staff ☐ Residential staff ☐ Other (please specify): Specify here
54. Medical Breathalyzer last calibration date Date*
55. Number of on-center smoking locations*

Obstetrical/Gynecological Services
56. Family Planning Program (FPP) coordinator is*	☐ HWD ☐ Staff Nurse ☐ CP/NP/PA ☐ Other (please specify): Specify here
57. Birth Control methods offered on-center (Check all that apply)*	☐ Condoms ☐ Oral Contraceptives ☐ Depo ☐ Patches ☐ Rings ☐ Long lasting methods (IUD or implant) ☐ Other (please specify): Specify here
58. What is the address of where off-center FPP services are conducted (if applicable)*
Name
Company
Address
Address 2
City/Town
State/Province
ZIP/Postal
Country

Pharmaceuticals and Medical Supplies
59. Vaccination Supplier (Check all that apply)*	☐ VFC ☐ Health Department ☐ Other (please specify): Specify here
60. Pharmaceutical Suppliers (list all)*
61. Medications*
Number of students currently on any daily medications
Number of students currently on psychotropic medications
Number of students currently on controlled medications
62. Location of student medication lockboxes (Check all that apply)*	☐ Dorm ☐ Recreation ☐ Security ☐ Other (please specify): Specify here
63. Emergency supplies available on center with 24/7 access (Check all that apply)*	☐ Narcan ☐ AED ☐ Grab and Go Kit ☐ Other (please specify)
64. Describe any other special services, outside agencies providing health-related services, and/or innovative programs not mentioned above*

Paperwork Reduction Act Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0035). Please do not submit completed forms to this address.

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