1. A. Medical Director ___________________________________________________
B. Number of Staff Physicians (excluding Medical
Director) F/T ______ P/T ______
2. Administrative Staff:
Administrator ____________________________ No. Assistants _________
(submit resume) (name)
Number in charge of Medical Records ________________________________
Person in charge of Medical Records ________________________________
Qualifications _____________________________________________________
Number of medical records clerks F/T _______ P/T ________
3. Other Employee Staffing:
| F/T | P/T | F/T | P/T | |
| Nurse Practitioners | ||||
| Housekeeping | ||||
| Maintenance | ||||
| Physician Assistants | ||||
| Others | ||||
| Pharmacists | ||||
| Laboratory Techs | ||||
| X-ray Techs | ||||
| Social Workers | ||||
| Respiratory Therapists | ||||
| Nutritionists |
F/T = full time P/T = part time