05-07,,,,,FORM CMS 1728-94,,,,,3290 (Cont.)
HOME HEALTH AGENCY,,,,,  PROVIDER NO.:,,  PERIOD:,,WORKSHEET S-3,
STATISTICAL DATA,,,,,,,From:  ___________,,PARTS I - III,
,,,,,  ______________,,To: ___________,,,
,,,,,,,,,,
PART I - STATISTICAL DATA,,,,,,COUNTY,Cook,,,
,,,,,,,,,,
,,,,Title XVIII,,Other,,Total,,
,     DESCRIPTION,,,Visits,Patients,Visits,Patients,Visits,Patients,
,,,,1,2,3,4,5,6,
 1, Skilled Nursing,,,,,,,,, 1
 2, Physical Therapy,,,,,,,,, 2
 3, Occupational Therapy,,,,,,,,, 3
 4, Speech Pathology,,,,,,,,, 4
 5, Medical Social Service,,,,,,,,, 5
 6, Home Health Aide,,,,,,,,, 6
 7, All Other Services,,,,,,,,, 7
 8, Total Visits,,,,,,,,, 8
 9, Home Health Aide Hours,,,,,,,,, 9
10, Unduplicated Census Count -,,,,,,,,,10
, Full Cost Reporting Period,,,,,,,,,
10.01, Unduplicated Census Count -,,,,,,,,,10.01 
, Pre 10/1/2000,,,,,,,,,
10.02, Unduplicated Census Count -,,,,,,,,,10.02 
, Post 9/30/2000,,,,,,,,,
,,,,,,,,,,
PART II - EMPLOYMENT DATA,,,,,,,,,,
(FULL TIME EQUIVALENT),,,,,,,,,,
,,,,,,,,,,
,Number of hours in,,,,,,,,,
,your normal work week __________,,,,,,Staff,Contract,Total,
,,,,,,,1,2 ,3,
11 ,Administrator and Assistant Administrator(s),,,,,,,,,11 
12 ,Director and Assistant Director(s),,,,,,,,,12 
13 ,Other Administrative Personnel,,,,,,,,,13 
14 ,Direct Nursing Service,,,,,,,,,14 
15 ,Nursing Supervisor,,,,,,,,,15 
16 ,Physical Therapy Service,,,,,,,,,16 
17 ,Physical Therapy Supervisor,,,,,,,,,17 
18 ,Occupational Therapy Service,,,,,,,,,18 
19 ,Occupational Therapy Supervisor,,,,,,,,,19 
20 ,Speech Pathology Service,,,,,,,,,20 
21 ,Speech Pathology Supervisor,,,,,,,,,21 
22 ,Medical Social Service,,,,,,,,,22 
23 ,Medical Social Supervisor,,,,,,,,,23 
24 ,Home Health Aide,,,,,,,,,24 
25 ,Home Health Aide Supervisor,,,,,,,,,25 
26 ,,,,,,,,,,26 
27 ,,,,,,,,,,27 
,,,,,,,,,,
PART III - METROPOLITAN STATISTICAL AREA (MSA) AND CORE BASED STATISTICAL AREA (CBSA) CODES,,,,,,,,,,
,,,,,,,,1 ,1.01 ,
,Enter the total number of MSAs in column 1 and/or CBSAs in column 2 where Medicare,,,,,,,,,
28 ,covered services were provided during the cost reporting period.,,,,,,,,,28 
,List all MSA and CBSA codes in which Medicare covered home health services were,,,,,,,MSA Codes,CBSA Codes,
29 ,provided during the cost reporting period (line 29 contains the first code):,,,,,,,,,29 
,,,,,,,,,,29.01 
,,,,,,,,,,29.02 
,,,,,,,,,,29.03 
,,,,,,,,,,29.04 
,,,,,,,,,,29.05 
,,,,,,,,,,29.06 
,,,,,,,,,,29.07 
,,,,,,,,,,29.08 
,,,,,,,,,,29.09 
"FORM CMS-1728-94 (5-2007)  (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,",,,,,,,,,,
SEC. 3205) ,,,,,,,,,,
,,,,,,,,,,
Rev. 13,,,,,,,,,,32-305