Initial Attestation and Workforce Report Form

Fiscal Intermediary Agency Contact Information

Total # of Employed should equal the total of the each of the following sections:
• Years of Service
• Ethnicity
• Race of employees

Workforce Report

Please indicate if data is unavailable with an “N/A” and fill-in as applicable.

Personal Care Aides

Race of Employees

Attestation

I recognize that the purpose of the HCBS workforce grant funds and administrative fees received by the Agency is to improve recruitment, retention, and capacity of the Personal Care Aide (PCA) workforce for Self-Directed programs.  I hereby attest that at least 85% of the grant funds shall be spent to provide recruitment and retention bonuses to PCAs and no more than 15% of the grant funds shall be spent on additional eligible payroll costs, via Qualifying Activities as described in Program Guidance.  I further attest that the administrative fees my agency receives related to this program shall be spent in accordance with Program Guidance. My agency will maintain payroll and financial records to support this attestation, and such payroll 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 commits to notifying EOHHS when we have spent 80% of grant funds.  My agency also commits to returning to EOHHS any Program funds not expended by the Program end date of April 30, 2023.  My agency will maintain and submit quarterly Expenditure Reports and Workforce Reports as required by EOHHS. 

By submitting this form, I hereby attest that, to the best of my knowledge and belief, that the above information is accurate and complete.