Self-Directed Workforce Quarterly Report Form

- Required Field

Please only leave a field blank if you do not collect the data in that field.

Agency Name

NPI #

Name of agency lead contact submitting report

Job title of lead contact

Phone for lead contact

Email of lead contact

Mailing address for lead contact: Address

Mailing address for lead contact: City/Town

Mailing address for lead contact: State/Province

Mailing address for lead contact: ZIP/Postal Code

Reporting Period

Reporting Period - Start Date

Reporting Period - End Date

Self Directed Workforce Report

Direct Care Workers (including Nursing Assistants)

# of Part-Time DCW Employees

# of Full-Time DCW Employees

# of DCW employees with less than 1 year of service

# of DCW employees with 1 to 5 years of service

# of DCW employees with 5+ years of service

# of DCW who speak a language other than English

Ethnicity of employees

Not Hispanic or Latinx

Hispanic or Latinx

Race of Employees

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Other Race

Unknown Race

Total Part-Time DCW employees hired during reporting period

Total Full-Time DCW employees hired during reporting period

Total Part-Time DCW employees terminated during reporting period

Total Full-Time DCW employees terminated during reporting period

Total current DCW job openings

Specify job titles for DCW job openings

Personal Care Aide

Other (Please describe)

Descriptions of other job openings

# of other job openings

# of Personal Care Aides

Expenditure Report: Additional Compensation Spending

Direct care workers (including Nursing Assistants)

Total Wage Increases for DCWs (Total elevated wage minus previous base wage)

Benefits

Overtime incentives

Incentives for hard-to-fill shifts or locations

Retention Bonus

Hiring Bonus

Wraparound benefits

Training Support

Other (Please describe)

Other Incentive Description

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 acknolwedges 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 shall return to EOHHS any program funds not expended by the Program end date of Mar 31, 2023.

Name: First

Name: Last

Date

Agency