Document
Form 2: Staffing Profile
ICR 202610-0915-001 · OMB 0915-0285 · Object 174057200.
Document Viewer [docx]
Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Form 2: Staffing Profile |
| Last Modified By | Writer |
| File Modified | 2026-07-09 |
| File Created | 2026-10-22 |
| Conversion State | complete |
Extracted Text
Form 2: Staffing Profile OMB No.: 0915-0285. Expiration Date: 06/30/2029 DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 2: STAFFING PROFILE FOR HRSA USE ONLY Grant Number Application Tracking Number 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 for position descriptions. Management and Support Personnel Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Project Director/Chief Executive Officer (CEO) N/A Finance Director/Chief Financial Officer (CFO) Chief Operations Officer (COO) Chief Information Officer (CIO) Clinical Director/Chief Medical Officer (CMO) Other Management and Support Personnel Facility and Non-Clinical Support Personnel Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Fiscal and Billing Personnel IT Personnel Facility Personnel Patient Support Personnel Physicians Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Family Physicians General Practitioners Internists Obstetrician/Gynecologists Pediatricians Other Specialty Physicians Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Nurse Practitioners Physician Assistants Certified Nurse Midwives Medical Care Services Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Nurses Other Medical Personnel (e.g. Medical Assistants, Nurse Aides) Please specify: (maximum 40 characters) << Add form field for 40 characters>> Laboratory Personnel X-Ray Personnel Dental Services Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Dentists Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Dental Hygienists Dental Therapists Other Dental Personnel Please Specify: (maximum 40 characters) << Add form field for 40 characters>> Behavioral Health (Mental Health and Substance Use Disorder Services) Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Psychiatrists Licensed Clinical Psychologists Licensed Clinical Social Workers Other Licensed Mental Health Providers Please Specify: (maximum 40 characters) << Add form field for 40 characters>> Other Mental Health Personnel Please Specify: (maximum 40 characters) << Add form field for 40 characters>> Substance Use Disorder Providers Professional Services Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Other Professional Health Services Personnel Please Specify: (maximum 40 characters) << Add form field for 40 characters>> Vision Services Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Ophthalmologists Optometrists Other Vision Care Personnel Please Specify: (maximum 40 characters) << Add form field for 40 characters>> Pharmacy Personnel Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Pharmacy Personnel Patient Support Services Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Case Managers Patient and Community Education Specialists Outreach Workers Transportation Workers Eligibility Assistance Workers Interpretation Personnel Community Health Workers Other Patient Support Services Personnel Please Specify: (maximum 40 characters) << Add form field for 40 characters>> Other Programs and Services Staffing Positions by Major Service Category Direct Hire FTEs Contract/Agreement FTEs Quality Improvement Personnel Other Programs and Services Personnel Please Specify: (maximum 40 characters) << Add form field for 40 characters>> Total FTEs Totals Direct Hire FTEs Contract/Agreement FTEs Totals Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) are patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients and adjust fees based on income and family size. 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. 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 information collection is 0915-0285 and it is valid until 06/30/2029. 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or [email protected]. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.