Form Cms-728 - Cms Staff Data

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 093 8-0378
CMS STAFF DATA
(Distinct Part Only)
Hospital
Survey Dates
Number of Unit/Wards
Average Daily Census
NURSING STAFF (FTEs) ASSIGNED TO DIRECT PATIENT CARE
Shift
R.N.
L.P.N.
M.H.W./Tech
Clinical Specialist
Day
Evening
Night
TOTAL
Signature of CMS Nurse Surveyor
Signature of Nursing Director
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0378. The time
required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If
you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
(OPTIONAL)
Form CMS-728 (09/94)

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