1. What type of organization do you work for?

Hospital Long-term Facility or System Health Plan Ancillary Service Provider Integrated Health System Physician Practice Home Health Other

Answer question #1a only if you selected "Hospital" in question #1 and are a single facility

1a. How many beds does your hospital have?

0 to 100 beds Between 100 and 200 beds More than 200 beds N/A

2. How many locations does your organization have?

One Location Several locations in one concentrated geographic area Several locations in separate geographic areas or states

3. How many total employees does your organization have? (Please enter your response below.)

4. Does your organization have a corporate compliance office/function?

Yes No

5. How many years has the compliance program been in existence? (Please enter your response below.)

6. How many persons are employed on the compliance staff? (Please enter your response below.)

7. Does the compliance function have its own budget or is it incorporated in some other department's budget? (Please enter your response below.)

8. Do you, the compliance officer, propose your own annual compliance budget?

Yes No Not the compliance officer

9. Do you have the ability to seek/obtain additional financial or other resources during the year if you believe such additional resources are necessary?

Yes No

10. Do you believe the budgeted amount for the current annual or fiscal year (as appropriate) is sufficient?

Yes No

Answer question #11 only if you answered "Yes" in question #10

11. Do you believe sufficient resources will continue to be allocated in the next annual/fiscal year?

Yes No N/A

12. Estimate your annual compliance budget.

under $50,000 $50,000 to $250,000 $250,000 to $500,000 $500,000 to $750,000 $750,000 to $1 million over $1 million

13. Is your compliance program budget broken down by functions; if so, does it include any of the following components?

a. Compliance staff salaries, benefits and overhead?

Yes No

b. Training and education?

Yes No

c. Compliance auditing and investigations?

Yes No

d. Internal reporting mechanisms and hotline operations?

Yes No

e. Employee screening for ineligible persons and background checks?

Yes No

f. Compliance program assessments and risk assessments?

Yes No

14. Estimate the annual budget for each of the compliance functions that has an individually identifiable annual budget amount?

a. Compliance office staff salaries, benefits and overhead?

under $50,000 $50,000 to $250,000 $250,000 to $500,000 $500,000 to $750,000 $750,000 to $1 million over $1 million

b. Training and education?

under $50,000 $50,000 to $250,000 $250,000 to $500,000 $500,000 to $750,000 $750,000 to $1 million over $1 million

c. Compliance auditing and investigations (internal and external costs)?

under $50,000 $50,000 to $250,000 $250,000 to $500,000 $500,000 to $750,000 $750,000 to $1 million over $1 million

d. Internal reporting mechanisms and/or hotline operations?

under $50,000 $50,000 to $250,000 $250,000 to $500,000 $500,000 to $750,000 $750,000 to $1 million over $1 million

e. Employee screening for ineligible persons and background checks?

under $50,000 $50,000 to $250,000 $250,000 to $500,000 $500,000 to $750,000 $750,000 to $1 million over $1 million

f. Compliance program assessments and risk assessments (internal and external costs)?

under $50,000 $50,000 to $250,000 $250,000 to $500,000 $500,000 to $750,000 $750,000 to $1 million over $1 million

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