To help determine the level of need for residential and ICF providers responding to COVID-19, the State of Ohio has requested the following data. This information will be used to help the state finalize its request for assistance from CMS. Responses are needed by close of business today, April 9, 2020. All information will be shared with state agencies in an effort to finalize a possible statewide provider relief plan.

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* 1. Contact Information (in case we need clarifications about your response)

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* 2. How many HPC staff did your agency have as of March 1, 2020? (If this does not apply to your agency, enter 0.)

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* 3. How many HPC staff has your agency lost to layoffs and natural attrition (i.e. staff choosing not to report) due to COVID-19? (If this does not apply to your agency, enter 0.)

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* 4. How many HPC staff has your agency hired since March 1 to help manage the COVID-19 crisis? (If this does not apply to your agency, enter 0.)

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* 5. How many ICF staff did your agency have as of March 1, 2020? (If this does not apply to your agency, enter 0.)

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* 6. How many ICF staff has your agency lost to layoffs and natural attrition (i.e. staff choosing not to report) due to COVID-19? (If this does not apply to your agency, enter 0.)

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* 7. How many ICF staff has your agency hired since March 1 to help manage the COVID-19 crisis? (If this does not apply to your agency, enter 0.)

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* 8. How many staff in other areas did your agency have as of March 1, 2020? (If this does not apply to your agency, enter 0.)

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* 9. How many staff in other areas has your agency lost to layoffs and natural attrition (i.e. staff choosing not to report) due to COVID-19? (If this does not apply to your agency, enter 0.)

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* 10. What was your agency's HPC budget as of March 1, 2020? (Approximate figures are acceptable.) (If this does not apply to your agency, enter 0.)

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* 11. What is your agency's HPC budget now? (This will be used to calculate how much your budget has increased.) (Approximate figures are acceptable.) (If this does not apply to your agency, enter 0.)

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* 12. How much of the change you specified above in your HPC budget is attributable to the following factors (please provide approximate cost figures if known). If a field does not apply to your agency, enter 0.

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* 13. What was your agency's ICF budget as of March 1, 2020? (Approximate figures are acceptable.) If this does not apply to your agency, enter 0.

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* 14. What is your agency's ICF budget now? (This will be used to calculate how much your budget has increased.) (Approximate figures are acceptable.) If this does not apply to your agency, enter 0.

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* 15. How much of the change you specified above in your ICF budget is attributable to the following factors (please provide approximate cost figures if known). If a field does not apply to your agency, enter 0.

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* 16. For ICF providers, have you experienced any savings resulting from the closure of adult day services?

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* 17. Please list in dollar amounts any other increases in costs attributable to COVID-19 (for any other services):

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