CMS Nursing Complement Data {CMS-727}

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0378 CMS NURSING COMPLEMENT DATA (for certified units) Hospital Survey Dates Unit/Ward Number of Beds Patient Type Census Please list staff actually on duty who are providing direct care to patients on this date for the entire shift. If a staff member covers 2 wards, list him/her as (.5); 4 wards = .25; etc. Non-NSG Personnel Shift R.N. L.P.N. M.H.W./Tech Ward Clerk Assigned to Unit Day Evening Night TOTAL Number of clinical specialists available (Masters prepared psychiatric nurses not counted in unit coverage) Signature of CMS Nurse Surveyor Signature of Nursing Director According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB number for this information collection is 0938-0378.The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and reviewthe 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-727 (09/94) (OPTIONAL)