One-Time Supplemental Payment for Home Health 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

Home Care 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

Nursing Assistant

Homemaker

Other (Please describe)

Descriptions of other job openings

# of other job openings

# of Nursing Assistants

# of Homemakers

Licensed Health Professionals (excluding Nursing Assistants)

# of Part-Time LHP Employees

# of Full-Time LHP Employees

# of LHP employees with less than 1 year of service

# of LHP employees with 1 to 5 years of service

# of LHP employees with 5+ years of service

# of LHP 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 LHP employees hired during reporting period

Total Full-Time LHP employees hired during reporting period

Total Part-Time LHP employees terminated during reporting period

Total Full-Time LHP employees terminated during reporting period

Total current LHP job openings

Specify job titles for LHP job openings

LPN

Other (Please describe)

Descriptions of other job openings

# of other job openings

# of RN

# of LPN

# of PT

# of OT

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
Development/Training: Cost of Training	Development/Training: Cost of Training amount	Development/Training: Cost of Training notes
Development/Training: Cost of Payments to Staff to Participate in Training	Development/Training: Cost of Payments to Staff to Participate in Training amount	Development/Training: Cost of Payments to Staff to Participate in Training notes
Development/Training: Cost of Stipends Paid to Staff Who Complete Training	Development/Training: Cost of Stipends Paid to Staff Who Complete Training amount	Development/Training: Cost of Stipends Paid to Staff Who Complete Training 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 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 March 31, 2024.

Name: First

Name: Last

Date

Agency

One-Time Supplemental Payment for Home Health Agencies

Required Key

- Required Field

Reporting Period

Home Care Workforce Report

Direct Care Workers (including Nursing Assistants)

Ethnicity of employees

Race of Employees

Licensed Health Professionals (excluding Nursing Assistants)

Ethnicity of employees

Race of Employees

Expenditure Report

Attestation