Form 2 Staffing Profile

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 2: STAFFING PROFILE YEAR 1  YEAR 2 	FOR HRSA USE ONLY
	Grant Number		Application Tracking Number
Note: 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 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 UDS manual for position descriptions.
PERSONNEL BYStaffing Positions by Major Service Category		TOTAL Direct Hire FTEs (a)	AVERAGE ANNUAL SALARY OF POSITION (b)Contract/Agreements FTEs	TOTAL SALARY (a*b)	Total Federal Support Requested
Key Management Staff/Administration
Project Director/Chief Financial Officer (CEO)			[_] Yes [_] No
Finance Director/Chief Financial Officer (Fiscal 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
Fiscal and Billing Staff			[_] Yes [_] No
IT Staff			[_] Yes [_] No
Facility Staff			[_] Yes [_] No
Patient Support Staff			[_] Yes [_] No
MEDICAL STAFFPhysicians
Medical/Clinical Director			[_] Yes [_] No
Family Physicians			[_] Yes [_] No
General Practitioners			[_] Yes [_] No
Internists			[_] Yes [_] No
OBObstetrician/GynecologistYNs			[_] Yes [_] No
Pediatricians			[_] Yes [_] No
Other Specialty Physicians Please Specify: (maximum 40 characters) ___________________			[_] Yes [_] No
Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives
Physician Assistants/Nurse Practitioners			[_] Yes [_] No
Physician Assistants			[_] Yes [_] No
Certified Nurse Midwives			[_] Yes [_] No
Medical
Nurses (RNs, LVNs, LPNs)			[_] Yes [_] No
Pharmacist, Pharmacy Support, Technicians			[_] Yes [_] No
Other Medical Personnel (e.g., Medical Assistants, Nurse Aides) Please Specify:______________________			[_] Yes [_] No
Laboratory Personnel (Lab Technicians)			[_] Yes [_] No
X-Ray Personnel			[_] Yes [_] No
Clinical Support Staff (Medical Assistants, etc.)			[_] Yes [_] No
Volunteer Clinical Providers (Medical and Dental)			[_] Yes [_] NoN/A	N/A	N/A
Dental STAFFServices
Dentists			[_] Yes [_] No
Dental Hygienists			[_] Yes [_] No
Dental Therapists			[_] Yes [_] No
Other Dental Assistants, Aides, TechniciansPersonnel			[_] Yes [_] No
Behavioral Health (Mental Health and Substance Abuse)STAFF
Behavioral Health Specialists (BH Provider)
Alcohol and Substance Abuse Specialists
Psychiatrists			[_] Yes [_] No
Licensed Clinical Psychologists			[_] Yes [_] No
Licensed Clinical Social Workers			[_] Yes [_] No
Other Licensed Mental Health Providers Please Specify: (maximum 40 characters) ___________			[_] Yes [_] No
Other Mental Health Staff Please Specify: (maximum 40 characters) ___________			[_] Yes [_] No
Substance Abuse Providers			[_] Yes [_] No
Professional Services
Other Professional Health Services Staff Please Specify: (maximum 40 characters) ___________			[_] Yes [_] No
Vision Services
Ophthalmologists			[_] Yes [_] No
Optometrists			[_] Yes [_] No
Other Vision Care Staff Please Specify: (maximum 40 characters) ___________			[_] Yes [_] No
Pharmacy
Pharmacy Personnel			[_] Yes [_] No
Enabling ServicesTAFF
Patient Education Specialists (Health Educators)
Case Managers			[_] Yes [_] No
Patient/ Community Education Specialists			[_] Yes [_] No
Outreach (Outreach Staff)Workers			[_] Yes [_] No
Transportation Staff			[_] Yes [_] No
Eligibility Assistance Workers			[_] Yes [_] No
Interpretation Staff			[_] Yes [_] No
Community Health Workers			[_] Yes [_] No
Other Enabling PersonnelServices Staff Please Specify (maximum 40 characters): ___________			[_] Yes [_] No
Other Programs and Services
Quality Improvement Staff			[_] Yes [_] No
OTHER PROFESSIONAL STAFF (discuss in narrative as appropriate)Other Programs and Services Staff Please Specify: (maximum 40 characters) ___________			[_] Yes [_] No
Total FTEs OTHER STAFF (discuss in narrative as appropriate)
		Direct Hire FTEs	Contract/Agreements FTEs
SALARY Totals		will auto-calculate in EHB	N/A

Public 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 14N-3910-33, Rockville, Maryland, 20857.