Form Sr 2b - Social Work Component Program Worksheet

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
SOCIAL WORK COMPONENT PROGRAM
PROVIDER NAME
PROGRAM NUMBER
MONTH/YEAR
WORKSHEET (SR 2B)
COLUMN A
COLUMN B
COLUMN C
COLUMN D
COLUMN E
Payroll /
Verified
"Direct Contact Hours Only" Social Work Contract
Social Work Professional Level
Total
Contract
Hours
Social Work
(1)
(2)
(3)
LCSW
MFT
MSW/ACSW
MSC
Master’s
Pre-1990
Hours
Weighted
Employee/Contractor Name
Direct Contact
Verified
Weighted
60 units
60 units
30 units -
or BSW
(2.5)
(2.5)
Worked /
(FCARB
Hours
Hours
Direct Contact
Direct
(2.0)
(2.0)
with elig.
+2 yrs. exp.
Reported
Use
Column A or
Reported
Hours
Contract Hours
to sit
(1.5)
Only)
C(3) x D
2 x Col. C(1)
(1.75)
TOTAL:
TOTAL:
TOTAL:
GH REP
FCARB REP
DATE
SR 2B (12/02)
Page ______ of ______

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