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CPM 2005-04 - Attachment B
Physicians' Comparability Allowance Reporting Worksheet
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Agency/Organizational Component: _________________
| Part I. PHYSICIANS ELIGIBLE FOR PCA |
Part II. PHYSICIANS RECEIVING PCA |
|||||
|---|---|---|---|---|---|---|
| FY 04 | FY 05 | FY 04 | FY 05 | |||
1) Total Number Employed |
||||||
| Category I | ||||||
| Category II | ||||||
| Category III | ||||||
| Category IV-A | ||||||
| Category IV-B | ||||||
| Total Number Employed | ||||||
| FY 04 | FY 05 | FY 04 | FY 05 | |||
2) Number of Physicians Signing: |
||||||
| One-year service agreement | ||||||
| Two-year service agreement | ||||||
| FY 04 | FY 05 | FY 04 | FY 05 | |||
3) Average Compensation per Physician: (Excluding PCA) |
||||||
| Category I | ||||||
| Category II | ||||||
| Category III | ||||||
| Category IV-A | ||||||
| Category IV-B | ||||||
| Average Compensation | ||||||
| FY 04 | FY 05 | FY 04 | FY 05 | |||
4) Average PCA Amount per Physician |
||||||
| Category I | ||||||
| Category II | ||||||
| Category III | ||||||
| Category IV-A | ||||||
| Category IV-B | ||||||
| Average PCA Amount | ||||||
| FY 04 | FY 05 | FY 04 | FY 05 | |||
5) Average PCA Amount per Physicians Signing: |
||||||
| One-year service agreement | ||||||
| Two-year service agreement | ||||||
| FY 04 | FY 05 | FY 04 | FY 05 | |||
6) Average PCA Amount per Physician with Federal Service of: |
||||||
| Less than Two Years | ||||||
| Two or More Years | ||||||
| FY 04 | FY 05 | FY 04 | FY 05 | |||
7) Average Number of Years Continuous Service Per Physician: |
||||||
| FY 04 | FY 05 | FY 04 | FY 05 | |||
8) Number and Rate of Accessions: |
||||||
| Category I | ||||||
| Category II | ||||||
| Category III | ||||||
| Category IV-A | ||||||
| Category IV-B | ||||||
| Total Number of Accessions | ||||||
| Accession Rate (for all | ||||||
| categories in %) | ||||||
| FY 04 | FY 05 | FY 04 | FY 05 | |||
9) Number and Rate of Separations: |
||||||
| Category I | ||||||
| Category II | ||||||
| Category III | ||||||
| Category IV-A | ||||||
| Category IV-B | ||||||
| Total Number of Separations | ||||||
| Separation Rate (for all | ||||||
| categories as %) | ||||||
| FY 04 | FY 05 | FY 04 | FY 05 | |||
10) Number and Rate of Unfilled FTEs: |
||||||
| Category I | ||||||
| Category II | ||||||
| Category III | ||||||
| Category IV-A | ||||||
| Category IV-B | ||||||
| Total Unfilled FTEs | ||||||
| Unfilled FTE Rate (for all | ||||||
| categories as %) | ||||||
| FY 04 | FY 05 | FY 04 | FY 05 | |||
11) Average Length of Time (months) Physician Position Vacant |
||||||
| 12) What is the estimated number of physicians in FY 2005 who will be receiving PCA's in the following dollar ranges: (a) $20,000-$24,999 and (b) $25,000-$30,000? | ||||||
| AGENCY/ORGANIZATION: | ||||||
| AGENCY CONTACT PERSON: | ||||||
| TELEPHONE NUMBER: | ||||||
| EMAIL ADDRESS: | ||||||
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