WEBSITE OF THE STATE OF SOUTH DAKOTA DEPARTMENT OF HEALTH
Kim Malsam-Rysdon, Secretary of Health

South Dakota Mental Care Full-Time Equivalent (FTE) Survey

Identifiable information from this survey will be used for calculating population-to-provider ratios for the State's applications for geographic and population health professional shortage area (HPSA) and medically underserved area/population (MUA/MUP) designations for mental care. This information must be collected for each relevant provider practicing in the State; complete and accurate responses will greatly assist the State in identifying areas with limited access to mental care so that these areas can be made eligible to receive additional health care resources. Please respond to all questions. Contact DeAnn Sprenger at 605-773-2679 for assistance.

Provider

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* Provider Status

Is Provider a Resident or Intern?
Is Provider a Current J-1 Visa Waiver Program Participant?
Is Provider a Federal Employee?
Is Provider a National Health Service Corps (NHSC) Employee?
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Practice Address 1 (Main)
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* Hours per week in DIRECT patient care activities (clinic and hospital inpatient) at this site
Direct patient care hours include: Clinic, in-hospital care activities such as rounds, etc, but EXCLUDE ER call, and all nursing home activities.

Percentage of the following patient groups the Provider sees at practice. If unknown please estimate:

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Practice Address 2 (Additional)
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* Hours per week in DIRECT patient care activities (clinic and hospital inpatient) at this site
Direct patient care hours include: Clinic, in-hospital care activities such as rounds, etc, but EXCLUDE ER call, and all nursing home activities.

Percentage of the following patient groups the Provider sees at practice. If unknown please estimate:

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Practice Address 3 (Additional)
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* Hours per week in DIRECT patient care activities (clinic and hospital inpatient) at this site
Direct patient care hours include: Clinic, in-hospital care activities such as rounds, etc, but EXCLUDE ER call, and all nursing home activities.

Percentage of the following patient groups the Provider sees at practice. If unknown please estimate:

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Practice Address 4 (Additional)
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* Hours per week in DIRECT patient care activities (clinic and hospital inpatient) at this site
Direct patient care hours include: Clinic, in-hospital care activities such as rounds, etc, but EXCLUDE ER call, and all nursing home activities.

Percentage of the following patient groups the Provider sees at practice. If unknown please estimate:

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*
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Practice Address 5 (Additional)
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* Hours per week in DIRECT patient care activities (clinic and hospital inpatient) at this site
Direct patient care hours include: Clinic, in-hospital care activities such as rounds, etc, but EXCLUDE ER call, and all nursing home activities.

Percentage of the following patient groups the Provider sees at practice. If unknown please estimate:

*
*
*
*
*
*
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Practice Address 6 (Additional)
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*
*
*
*
* Hours per week in DIRECT patient care activities (clinic and hospital inpatient) at this site
Direct patient care hours include: Clinic, in-hospital care activities such as rounds, etc, but EXCLUDE ER call, and all nursing home activities.

Percentage of the following patient groups the Provider sees at practice. If unknown please estimate:

*
*
*
*
*
*
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** Note: Sliding Fee is a formal posted up-front discount policy based on income or ability to pay and is tied to the Federal Poverty Levels. (see http://aspe.hhs.gov/POVERTY/) - bad debt write-offs are not included.

Thank you for your assistance with this important effort.