02-06		                                FORM CMS-2552-96					        3690 (Cont.)																								
HOSPITAL-BASED OUTPATIENT REHABILITATION				 PROVIDER NO.:	PERIOD:	WORKSHEET S-6																									  .
PROVIDER STATISTICAL DATA				 _______________	FROM__________																										
				 COMPONENT NO.:	TO_____________																										
				 _______________																											
																															
OUTPATIENT REHABILITATION PROVIDER - NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT)																															
																															
Check 		  [  ]  CMHC     [  ]  OOT																													
Applicable		  [  ]  CORF      [  ]  OSP																													
Box		  [  ]  OPT																													
																															
Enter the number of hours in your normal workweek __X																															
																															
						Total																									
				Staff	Contract	(col. 1 + col. 2)																									
				1	2	3																									
1 	Administrator and Assistant Administrator(s)			X	X		1 																								
2 	Director(s) and Assistant Director(s)			X	X		2 																								
3 	Other Administrative Personnel			X	X		3 																								
4 	Direct Nursing Service			X	X		4 																								
5 	Nursing Supervisor			X	X		5 																								
6 	Physical Therapy Service			X	X		6 																								
7 	Physical Therapy Supervisor			X	X		7 																								
8 	Occupational Therapy Service			X	X		8 																								
9 	Occupational Therapy Supervisor			X	X		9 																								
10 	Speech Pathology Service			X	X		10 																								
11 	Speech Pathology Supervisor			X	X		11 																								
12 	Medical Social Service			X	X		12 																								
13 	Medical Social Service Supervisor			X	X		13 																								
14 	Respiratory Therapy Service			X	X		14 																								
15 	Respiratory Therapy Supervisor			X	X		15 																								
16 	Psychiatric/Psychological Service			X	X		16 																								
17 	Psychiatric/Psychological Service Supervisor			X	X		17 																								
18 	Other (specify)			X	X		18 																								
																															
																															
19 	"Is this component paid 100% under established fee schedules?  If yes, enter ""Y"" , if no, enter ""N"".  If ""Yes"" you are not required"						19 																								
	to complete lines 1 through 18 above nor the related J series worksheets for cost reporting periods beginning on or after 4/1/2001.					X																									
																															
																															
																															
																															
																															
																															
																															
																															
																															
																															
																															
																															
																															
																															
																															
																															
																															
																															
																															
																															
"FORM CMS-2552-96 (8/2002)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3608.1)"																															
																															
																															
Rev. 15							              36-509