Form 1 workforce survey

Work Force Recruitment in BPHC-Funded Health Centers
Welcome

Dear Health Center Colleagues, 

Thank you for your participation in this brief survey regarding veterans in the health center workforce. This data collection 
will enable us to provide the training and technical assistance needed to support health centers in their hiring efforts. 

Your participation in this survey is voluntary but we encourage all health centers to actively participate. 

Thank you, 

BPHC 

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it 
displays a currently valid OMB control number. The OMB control number for this project is 0915­0353. Public reporting burden for this collection of 
information is estimated to average 0.5 hours per response, including the time for reviewing instructions, searching existing data sources, and 
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of 
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10­29, Rockville, 
Maryland, 20857. 

OMB Number (0915­0353) ­ Expiration date (2/29/2016) 

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Work Force Recruitment in BPHC-Funded Health Centers

1. Please provide the name of your organization and your Bureau of Primary Health Care
Management Information System (BHCMIS) identification in the space provided below.
Organization Name:
State:

6

BHCMIS ID:

OMB Number (0915­0353) ­ Expiration date (2/29/2016) 

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Work Force Recruitment in BPHC-Funded Health Centers

2. Next to the employment categories provided below, please identify the number of
current vacancies at your organization. (These are the same categories found in Table 5 of
the Uniform Data System ­ UDS)
# of Current Vacancies
Family physician, general practitioner internists, obstetrician/gynecologists, pediatricians, or other specialty 

6

physicians
Nurse practitioner, physician assistant, certified nurse midwife

6

Nurse, laboratory personnel, x­ray personnel or other medical personnel

6

Dentist, dental hygienist, dental assistant, dental aide, dental tech

6

Psychiatrist, licensed clinical psychologist, licensed clinical social worker or other mental health staff

6

Ophthalmologist, optometrist or other vision care staff

6

Pharmacy personnel

6

Case manager, health education specialist, outreach worker, transportation staff, eligibility assistance worker, 

6

interpretation staff

6

Management and support staff, fiscal and billing staff, IT staff, facility staff, patient support staff

OMB Number (0915­0353) ­ Expiration date (2/29/2016) 

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Work Force Recruitment in BPHC-Funded Health Centers
The next set of questions (3, 4, 5 & 6) will ask about new employees hi...

3. Please identify the number of employment vacancies filled by new employees hired
since August 2012.
# of Current Vacancies
Family physician, general practitioner internists, obstetrician/gynecologists, pediatricians, or other specialty 

6

physicians
Nurse practitioner, physician assistant, certified nurse midwife

6

Nurse, laboratory personnel, x­ray personnel or other medical personnel

6

Dentist, dental hygienist, dental assistant, dental aide, dental tech

6

Psychiatrist, licensed clinical psychologist, licensed clinical social worker or other mental health staff

6

Ophthalmologist, optometrist or other vision care staff

6

Pharmacy personnel

6

Case manager, health education specialist, outreach worker, transportation staff, eligibility assistance worker, 

6

interpretation staff
Management and support staff, fiscal and billing staff, IT staff, facility staff, patient support staff

6

OMB Number (0915­0353) ­ Expiration date (2/29/2016) 

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Work Force Recruitment in BPHC-Funded Health Centers

4. Please approximate how long each employment vacancy was open for until being filled
by new employees hired since August 2012. (Provide an average if there was more than
one position open within an employment category)
Less than 6 
months

6 to 12 months

More than 12 
months

Not applicable

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Nurse practitioner, physician assistant, certified nurse midwife

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Nurse, laboratory personnel, x­ray personnel or other medical personnel

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Dentist, dental hygienist, dental assistant, dental aide, dental tech

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Psychiatrist, licensed clinical psychologist, licensed clinical social worker 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Ophthalmologist, optometrist or other vision care staff

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Pharmacy personnel

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Case manager, health education specialist, outreach worker, 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Family physician, general practitioner internists, 
obstetrician/gynecologists, pediatricians, or other specialty physicians

or other mental health staff

transportation staff, eligibility assistance worker, interpretation staff
Management and support staff, fiscal and billing staff, IT staff, facility 
staff, patient support staff

OMB Number (0915­0353) ­ Expiration date (2/29/2016) 

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Work Force Recruitment in BPHC-Funded Health Centers

5. Please specify the number of any new civilian or military veteran employees hired by
your organization since August 2012.
# of Current Vacancies
Civilian (No military service history)

6

Military Veteran

6

OMB Number (0915­0353) ­ Expiration date (2/29/2016) 

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Work Force Recruitment in BPHC-Funded Health Centers

6. If you hired any veterans since August 2012, in general what were their years of service
in the military? (Check all that apply)
c 1960­1969
d
e
f
g
c 1970­1979
d
e
f
g
c 1980­1989
d
e
f
g

c 1990­1999
d
e
f
g
c 2000­2009
d
e
f
g
c 2010­2012
d
e
f
g

c Currently active
d
e
f
g

OMB Number (0915­0353) ­ Expiration date (2/29/2016) 

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Work Force Recruitment in BPHC-Funded Health Centers

7. Please identify the number of employment vacancies filled by military veterans hired
since August 2012.
# of Current Vacancies
Family physician, general practitioner internists, obstetrician/gynecologists, pediatricians, or other specialty 

6

physicians
Nurse practitioner, physician assistant, certified nurse midwife

6

Nurse, laboratory personnel, x­ray personnel or other medical personnel

6

Dentist, dental hygienist, dental assistant, dental aide, dental tech

6

Psychiatrist, licensed clinical psychologist, licensed clinical social worker or other mental health staff

6

Ophthalmologist, optometrist or other vision care staff

6

Pharmacy personnel

6

Case manager, health education specialist, outreach worker, transportation staff, eligibility assistance worker, 

6

interpretation staff
Management and support staff, fiscal and billing staff, IT staff, facility staff, patient support staff

6

Thank you for your participation in this effort. Please visit our website for helpful recruitment and retention resources 
(http://bphc.hrsa.gov/technicalassistance/index.html) as well as information specific to hiring veterans (http://bphc.hrsa.gov/veterans/index.html). 

OMB Number (0915­0353) ­ Expiration date (2/29/2016) 

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