Form 2 - Bureau of Primary Health Care
OMB No.: 0915-0285. Expiration Date: 9/30/2016DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Form 2: STAFFING PROFILE FOR HRSA USE ONLYGrant NumberApplication Tracking NumberNote: Allocate staff time by function among the staff 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 medical director should be listed in each respective category, with the FTE percentage allocated to each position (e.g., CMO 30% FTE and family physician 70% FTE). Do not exceed 100% FTE for any individual. Refer to the UDS manual for position descriptions. Do not report contracted staff or volunteers on this form.Staffing Positions by Major Service CategoryTotal FTEs (a)Average Annual Salary of Position (b)Total Salary (a*b)will auto-calculate in EHBTotal Federal Support RequestedAdministration/ManagementExecutive Director/CEOFinance Director/Chief Fiscal Officer/CFOChief Operating Officer/COOChief Information Officer/CIOMedical Director/Chief Medical Officer/CMOAdministrative Support StaffFacility and Non-Clinical Support StaffFiscal and Billing StaffIT StaffFacility StaffPatient Support StaffPhysiciansFamily PhysiciansGeneral PractitionersInternistObstetrician/GynecologistPediatriciansOther Specialty PhysiciansPlease Specify:NP, PA, and CNMsNurse PractitionersPhysician AssistantsCertified Nurse MidwivesMedicalNursesOther Medical Personnel (e.g. Medical Assistants, Nurse Aides)Laboratory PersonnelX-Ray PersonnelDental ServicesDentistsDental HygienistsDental Assistants, Aides, TechniciansBehavioral Health (Mental Health and Substance Abuse)PsychiatristsLicensed Clinical PsychologistsLicensed Clinical Social WorkersOther Mental Health StaffPlease Specify:Other Licensed Mental Health ProvidersPlease Specify:Substance Abuse ProvidersProfessional ServicesOther Professional Health Services Staff Please Specify:Vision ServicesOphthalmologistsOptometristsOther Vision Care StaffPlease Specify:Pharmacy Pharmacy PersonnelEnabling ServicesCase ManagersPatient/Community Education SpecialistsOutreach WorkersTransportation StaffEligibility Assistance WorkersInterpretation StaffOther Enabling Services StaffPlease Specify:Other Programs and ServicesOther Programs and Services StaffPlease Specify:Total FTEs, Salary and Federal Funds RequestedTotalsTotal FTEs (a)Average Annual Salary of Position (b)Total Salary (a*b)Total Federal Support RequestedThis row displays the sum of Total FTEs, Total Salary, and Total Federal Support Requested for all staff categories.will auto-calculate in EHBN/Awill auto-calculate in EHBwill auto-calculate in EHBPublic 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- ................
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