Form Sr 2a-Ctf-Nurse - Child Care And Supervision Component Program Worksheet Page 2
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1
2INSTRUCTIONS TO COMPLETE
CHILD CARE AND SUPERVISION COMPONENT PROGRAM WORKSHEET (SR 2A-CTF-NURSE)
PROVIDER NAME: Enter the provider/licensee name shown on the
COLUMN D - TRAINING
Group Home Program Rate Application (SR1).
40+HOURS - Enter 0.60 for all staff if the provider furnishes 40 or
more hours of formal training per year/FTE (Full-Time Equivalent)
MONTH/YEAR:
Month and year for hours worked
for child care nurse staff.
NURSE’S NAME:
List names of all nursing staff members who are
COLUMN E - WEIGHTING
performing child care and first-line supervision
Enter 1.0 and sum of weightings from Columns C and D.
activities.
(Maximum total cannot exceed 1.75.)
COLUMN A - PAID-AWAKE HOURS - Enter the total number of
COLUMN F - TOTAL WEIGHTED HOURS
paid-awake hours for each nurse providing child care and
Multiply Column A times Column E.
first-line supervision, including hours of paid vacation or sick
leave. (Maximum weekly totals per individual cannot exceed
COLUMN A - TOTAL
54 hours.) Transfer to SR 2, Column (2).
Enter the grand total paid-awake hours, transfer to SR 2,
Column 2.
COLUMN B - VERIFIED HOURS - Providers do not complete. For FCARB
USE ONLY
COLUMN F - TOTAL
Enter the grand total weighted hours; transfer to SR 2,
COLUMN C - EDUCATION/EXPERIENCE
Column (3).
Enter the weighting for each staff member according to his/her
respective professional level.
Example: If the service is provided by a licensed vocational
nurse, enter 0.50 weighting in the appropriate LVN column in
Column C. If the service is provided by a licensed registered
nurse with two years experience in psychological nursing, enter
2.40 in the appropriate column in Column C.
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