SFY 2024 One-Time Supplemental Payment for Adult BH Agencies

- Required Field

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

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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

Adult Behavioral Health Workforce Report

# of Part-Time Employees

# of Full-Time Employees

# of employees with less than 1 year of service

# of employees with 1 to 5 years of service

# of employees with 5+ years of service

# of 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 employees hired during reporting period

Total Full-Time employees hired during reporting period

Total Part-Time employees terminated during reporting period

Total Full-Time employees terminated during reporting period

Total current job openings

Expenditure Report

Spending Category	Amount Spent in Reporting Period	Notes/Explanations
Recruitment Activities	Recruitment activities amount	Recruitment activities notes
Recruitment Bonus	Recruitment bonus amount	Recruitment bonus notes
Retention Bonus	Retention bonus amount	Retention bonus notes
Administrative expenses (not to exceed 15%)	Administrative expenses amount	Administrative expenses notes

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 shall return to EOHHS any program funds not expended by the Program end date of December 1, 2024.

Name: First

Name: Last

Date

Agency