DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0378 DATA COLLECTION MEDICAL STAFF COVERAGE (certified beds only) Hospital Date FULL-TIME (FTEs ) PART-TIME (PTEs ) COMMENTS 1. Medical Staff Coverage Board Certified MDs (Psy.) Fully Trained MDs (Psy.) Board Certified MDs (Neuro.) Fully Trained MDs (Neuro.) Internist (Specialty) Family Practice (Boarded) Physicians with Limited Licensure General Practice Physician Assistants 2. Other (specify, for example Consultants who spend time at the hospital) 3. If residents are utilized for work assignments, specify FTEs and assignm ents, as well as numbers and the amount of hospital staff time used for supervision. 4. Specify how On-Call medical coverage and assignments are handled (nights, weekends, and holidays) 5. Vacancies 6. On leave Signature of CMS Surveyor Signature of Clinical Director According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of infor mation unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0378. The time required to complete this information collection is estimated t o average 30 minutes per response, including the time to review instructions, search existing data res ources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. FORM CMS-729 (09/94) (OPTIONAL)