*** Use your tab and shift tab keys to navigate the data fields. Do not hit the enter key until you are ready to leave the form.***

NPI Number

Facility Name

Phone

Street Address

City

State

Zip

Name of Contact

Email

Please enter 0 or N/A if not applicable

Part I: CNA Data

1	CNA Employee Salary Cost
2	CNA Employee Benefits Cost
3	CNA Employee Hours Worked
4	CNA Employee Paid Leave Hours
5	CNA Outside Agency Personnel Cost
6	CNA Outside Agency Hours Purchased
7	CNA Corporate Agency and/or Related Personnel Cost
8	CNA Corporate Agency and/or Related Party Hours Purchased

Part II: LPN Data

9	LPN Employee Salary Cost
10	LPN Employee Benefits Cost
11	LPN Employee Hours Worked
12	LPN Employee Paid Leave Hours
13	LPN Outside Agency Personnel Cost
14	LPN Outside Agency Hours Purchased
15	LPN Corporate Agency and/or Related Personnel Cost
16	LPN Corporate Agency and/or Related Party Hours Purchased

Part III: RN Data

17	RN Employee Salary Cost
18	RN Employee Benefits Cost
19	RN Employee Hours Worked
20	RN Employee Paid Leave Hours
21	RN Outside Agency Personnel Cost
22	RN Outside Agency Hours Purchased
23	RN Corporate Agency and/or Related Personnel Cost
24	RN Corporate Agency and/or Related Party Hours Purchased

Part IV: Non-Nursing Data

Reference Schedule A-3 or B-5, Part 1, of the PIRS 1090 Series as a basis for allocations. Do not include therapy costs in the part of costs allocated from the home office.

25	Non-Nursing Employee Salary Cost
26	Non-Nursing Employee Benefits Cost
27	Non-Nursing Employee Hours Worked
28	Non-Nursing Employee Paid Leave Hours
29	Non-Nursing Outside Agency Personnel Cost
30	Non-Nursing Outside Agency Hours Purchased
31	Non-Nursing Corporate Agency and/or Related Personnel Cost
32	Non-Nursing Corporate Agency and/or Related Party Hour Purchased

Part V: Therapist Data

Employee only, not agency personnel

33	Therapist Employee Salary Cost (IT/RT, OT & Speech)
34	Therapist Employee Benefits Cost (IT/RT, OT & Speech)

Part VI: Total Salary Costs

Sum of lines 1, 9, 17, 25 and 33

35

Salary Costs of All Nursing Home Employees

Part VII: Benefit Cost Data

Sum of lines 2, 20, 28, 26, and 34

36

Employee Total Benefit Cost

Part VIII: Liability Insurance Data

If separate premiums for Professional, General and Umbrella coverage are not available, provide total premium only

Past year (2008) Insurance Premium Paid

37	Professional Liability Premium
38	General Liability Premium
39	Umbrella Coverage Premium
40	Total Premium (Professional Liability, General Liability and Umbrella Coverage Premiums)
41	Past Year Deductibles Paid

Coming Year (2009) Insurance Premium

42

Total Premium (Professional Liability, General Liability and Umbrella Coverage Premiums)

	INSTRUCTIONS FOR REPORTING ADDITIONAL INFORMATION
	The nursing staff information requested below should include all nursing staff as defined in section 2 of the cost data instructions excluding agency and corporate nursing staff.

Part IX: Nursing Staff Turnover/Retention

43	Number of Nursing Staff Employed on January 1, 2008 (CNA, LPN, RN)
44	Number of Nursing Staff Employed on December 31, 2008 (CNA, LPN, RN)
45	Number of Nursing Staff Hired During Year (CNA, LPN, RN)
46	Number of Nursing Staff Whose Employment Ended During Year (CNA, LPN, RN)
47	Number of Nursing Staff Employed For All of Year (CNA, LPN, RN)

Part X: Total Bed Days

48

Total Bed Days of All Nursing Home Residents

Please remember to print a copy of this form for your records before hitting the 'Submit Nursing Facility Wage Survey Data to DMAS' button.