Enhanced Outpatient Services Workforce Quarterly Report Form Required Key - Required Field Please only leave a field blank if you do not collect the data in that field. Agency Name Agency Name NPI NPI # Contact Name Name of agency lead contact submitting report Contact Job Title Job title of lead contact Contact Phone Phone for lead contact Contact Email Email of lead contact Agency Address Mailing address for lead contact: Address Agency City/Town Mailing address for lead contact: City/Town Agency State Mailing address for lead contact: State/Province - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Agency Zip Mailing address for lead contact: ZIP/Postal Code Reporting Period Reporting Period Start Date Reporting Period - Start Date Reporting Period End Date Reporting Period - End Date EOS Workforce Report Direct Care Workers (including Nursing Assistants) DCW Part-Time Employees # of Part-Time DCW Employees DCW Full-Time Employees # of Full-Time DCW Employees DCW Service Time 0-1 yr # of DCW employees with less than 1 year of service DCW Service Time 1-5 yrs # of DCW employees with 1 to 5 years of service DCW Service Time 5+ yrs # of DCW employees with 5+ years of service DCW Language other than English # of DCW who speak a language other than English Ethnicity of employees DCW Ethnicity Not Hispanic/Latinx Not Hispanic or Latinx DCW Ethnicity Hispanic/Latinx Hispanic or Latinx Race of Employees DCW Race White White DCW Race Black/African American Black or African American DCW Race Am Indian/AK Native American Indian or Alaska Native DCW Race Asian Asian DCW Race Native Hawaiian/Pacific Islander Native Hawaiian or Other Pacific Islander DCW Race Other Other Race DCW Race Unknown Unknown Race DCW # Hired PT Total Part-Time DCW employees hired during reporting period DCW # Hired FT Total Full-Time DCW employees hired during reporting period DCW # Terminated PT Total Part-Time DCW employees terminated during reporting period DCW # Terminated FT Total Full-Time DCW employees terminated during reporting period DCW Job Openings Total Total current DCW job openings DCW Job Opening Titles Specify job titles for DCW job openings Case Manager Other (Please describe) DCW Other Description Descriptions of other job openings DCW Other Count # of other job openings Case Manager Count # of Case Managers Licensed Health Professionals (excluding Nursing Assistants) LHP Part-Time Employees # of Part-Time LHP Employees LHP Full-Time Employees # of Full-Time LHP Employees LHP Service Time 0-1 yr # of LHP employees with less than 1 year of service LHP Service Time 1-5 yrs # of LHP employees with 1 to 5 years of service LHP Service Time 5+ yrs # of LHP employees with 5+ years of service LHP Language other than English # of LHP who speak a language other than English Ethnicity of employees LHP Ethnicity Not Hispanic/Latinx Not Hispanic or Latinx LHP Ethnicity Hispanic/Latinx Hispanic or Latinx Race of Employees LHP Race White White LHP Race Black/African American Black or African American LHP Race Am Indian/AK Native American Indian or Alaska Native LHP Race Asian Asian LHP Race Native Hawaiian/Pacific Islander Native Hawaiian or Other Pacific Islander LHP Race Other Other Race LHP Race Unknown Unknown Race LHP # Hired PT Total Part-Time LHP employees hired during reporting period LHP # Hired FT Total Full-Time LHP employees hired during reporting period LHP # Terminated PT Total Part-Time LHP employees terminated during reporting period LHP # Terminated FT Total Full-Time LHP employees terminated during reporting period LHP Job Openings Total Total current LHP job openings LHP Job Opening Titles Specify job titles for LHP job openings Social Worker Mental Health Counselor RN Other (Please describe) LHP Other Description Descriptions of other job openings LHP Other Count # of other job openings Social Worker Count # of Social Workers Mental Health Counselor Count # of Mental Health Counselors RN Count # of RN OT Count # of OT Expenditure Report: Additional Compensation Spending Direct care workers (including Nursing Assistants) DCW Incentive Wage Increase Total Wage Increases for DCWs (Total elevated wage minus previous base wage) DCW Incentive Additional Benefits Benefits DCW Incentive Additional Overtime Incentive Overtime incentives DCW Incentive Additional Differental Incentive Incentives for hard-to-fill shifts or locations DCW Incentive Additional Retention Bonus Retention Bonus DCW Incentive Hiring Bonus Hiring Bonus DCW Incentive Wraparound Benefits Wraparound benefits DCW Incentive Training Support Training Support DCW Incentive Other Other (Please describe) DCW Incentive Other Description Other Incentive Description Licensed Health Profressionals (excluding Nursing Assistants) LHP Incentive Wage Increase Total Wage Increases for LHPs (Total elevated wage minus previous base wage) LHP Incentive Additional Benefits Benefits LHP Incentive Additional Overtime Incentive Overtime incentives LHP Incentive Additional Differental Incentive Incentives for hard-to-fill shifts or locations LHP Incentive Additional Retention Bonus Retention Bonus LHP Incentive Hiring Bonus Hiring Bonus LHP Incentive Wraparound Benefits Wraparound benefits LHP Incentive Training Support Training Support LHP Incentive Other Other (Please describe) LHP Incentive Other Description Other Incentive Description Administrative Payroll Cost Increase $ Increased administrative payroll costs related to additional compensation above Attestation I hereby attest that, to the best of my knowledge and belief, that the above information is accurate and complete. My agency has maintained personnel records to support this attestation and acknowledges that such personnel records may be subject to audit by EOHHS. In the event that EOHHS determines that Program funds have been used for ineligible expenses, my agency may be required to repay such funds to EOHHS. My agency is aware that ALL enhanced HCBS funds must be expended no later than September 30, 2023. Attestation First Name Name: First Attestation Last Name Name: Last Attestation Date Date Attestation Agency Name Agency Leave this field blank