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* 1. Center Name

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* 2. Region

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* 3. Contracted OBS

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* 4. Center Current OBS

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* 5. Your Name

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* 6. Your Title

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* 7. Your Email Address

Reporting Period : If you are filling this form out between October 1 and 10, 2021 -  the correct corresponding reporting period is July-September 2021.

The reporting period is the 3 month period prior to when the report is due.

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* 8. Reporting Period

Wellness Staffing Center Current Information

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* 9. Position on center: Physician

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* 10. Position on center: Physician Assistant

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* 11. Position on center: Nurse Practitioner

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* 12. Position on center: Health and Wellness Manager

For # 13, Other Nursing Staff

Include the total number of hours worked by all other nursing staff (not Nurse Practitioners). Please also list how many hours are held by RNs and how many hours are held by LPNs.

If you have more than one nurse employed in other nursing staff, include the number and positions of nurses employed in the "Notes and Comments" section at the bottom of the survey.

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* 13. Position on center: Other Nursing Staff

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* 14. Position on center: Mental Health Consultant

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* 15. Position on center: TEAP Specialist

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* 16. Position on center: Dentist

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* 17. Position on center: Dental Hygienist

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* 18. Position on center: Dental Assistant

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* 19. Position on center: Clerical

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* 20. Position on center: Health Services Administrator (>700 students)

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* 21. Position on center: Mental Health Interns (NOT REQUIRED)

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* 22. Position on center: 1) Other

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* 23. Position on center: 2) Other

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* 24. Position on center: 3) Other

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* 25. Position on center: 4) Other

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* 26. Position on center: 5) Other

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* 27. Are there any waivers in place for Wellness staff (i.e. TEAP Specialist, CMHC, etc)?

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* 28. Notes and Comments-

This section is for ALL notes and comments. Additionally, if you have any positions which are off center, include that here as well.

Thank you for submitting the quarterly Health and Wellness Center Staffing report.

A confirmation will be sent within the next 15 minutes to the e-mail address supplied above containing the submitted responses.

If you have any questions or concerns, contact Leah Pan at Leah.Pan@humanitas.com.

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