Form Sr 2b - Social Work Component Program Worksheet Page 2
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2INSTRUCTIONS TO COMPLETE SOCIAL WORK
COMPONENT PROGRAM WORKSHEET (SR 2B)
PROVIDER NAME:
Enter the provider/licensee name shown on the Group Home
COLUMN D - SOCIAL WORK PROFESSIONAL LEVEL
Program Rate Application (SR 1).
Enter 2.5, if a Licensed Clinical Social Worker; OR
PROGRAM NUMBER:
For an Annual or Program Change, enter the number
previously assigned by DSS. For an Initial, leave blank.
Enter 2.5, if a Licensed Marriage and Family Therapist; OR
MONTH/YEAR:
Month and year for hours worked.
Enter 2.0, if a Master’s of Social Work/ACSW (60 units); OR
EMPLOYEE/CONTRACTOR NAME:
List names of each qualified staff member or
Enter 2.0, If a Master’s of Science in Counseling (60 units); OR
contractor performing social work activities.
Enter 1.75, if a Master’s (30 units) in a discipline which would enable the
COLUMN A - PAYROLL/CONTRACT HOURS WORKED/REPORTED
person to sit for the LCSW/MFT exam; OR
Enter the total number of paid-awake hours worked, including paid
Enter 1.5, if pre-1990 or Bachelor of Social Work with at least two years of
vacation and/or sick leave. Most contracts will be reported in this space.
experience.
COLUMN B - VERIFIED HOURS
COLUMN E - TOTAL SOCIAL WORKER WEIGHTED HOURS
Providers do not complete. For FCARB use only.
Enter the total of COLUMN A OR C(3) multiplied by Column D.
COLUMN C - SOCIAL WORK CONTRACT, DIRECT HOURS ONLY
COLUMN A/C(3) - TOTAL
Subcolumn (1) - Enter only the number of direct (face-to-face) services as
Enter the total of Column A and Column C(3); transfer to SR 2, Column (5).
specified by a written contract. Contracts listed in this column must be
limited to direct services only. These contracts do not include any other
COLUMN E - TOTAL
responsibilities or duties (e.g., preparation or completion of paperwork,
consultation, program design, etc.) – only DIRECT SERVICE HOURS!
Enter the total weighted hours; transfer to SR 2, Column (6).
Subcolumn (2) - Providers do not complete. For FCARB use only.
Subcolumn (3) - The hours of social work activities provided on a
contractual basis will be weighted an additional 2.0 only if certain
qualifications are met. For example: (1) the person providing social work
activities is not on payroll (i.e., not an employee of the group home); and
(2) the contracted hours are limited to only direct (face-to-face) contact
with the children. See regulation Section 11-402.222(d) for details.
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