FHT Schedules IFA PSA MGA 08 05 08 V2 3

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FHT Schedules IFA PSA MGA 08 05 08 V2 3 Powered By Docstoc
					                                                                                                                                                                                                                   Schedule "A"
                                                                                                                                                                                                                  FHT Service Plan
                                                                                                                                                                                              [insert name of] Family Health Team, FHT Group #: XXX
                                                                                                                                                                                                                   For the Period
                                                                                                                                                                                                                   April 1, 2XXX
                                                                                                                                                                                                                         to
                                                                                                                                                                                                                 March 31, 2XXX
                                                                                                                                                                                                  PATIENT ENROLMENT TARGETS
                                                                                                                                                               Enrolled Patients as of April 1, 2008                                                             Target Enrolment for March 31, 2009                                                          Target Unattached Patient Enrolment1
                                                                                                                             Number of Patients:                                                                                       Number of Patients:                                                                        Number of Patients:
                                                                                                                                                                                                       PROGRAMS AND SERVICES
                                                                                                                                                                                                                                                                                       Psychologists /
                                                                                                                                                                                          Registered Practical                                                                                                 Chiropodists /
                                                                                                                                # Eligible   Nurse Practitioners   Registered Nurses                           Registered Dieticians       Pharmacists           Social Workers        Psychological                                   Other IHPs2:           Other IHPs2:           Other IHPs2:              All IHPs:
                                                                                                                                                                                                Nurses                                                                                                          Podiatrists
                                                                                                                                 Patients                                                                                                                                                Associates

                                                                                                                                                   Total FTE            Total FTE               Total FTE           Total FTE               Total FTE              Total FTE              Total FTE              Total FTE              Total FTE               Total FTE              Total FTE              Total FTE

                                                                           Col 1                                                     Col 2           Col 3                 Col 4                  Col 5                Col 6                   Col 7                 Col 8                  Col 9                  Col 10                 Col 11                  Col 12                 Col 13                 Col ZZ
                             Services
Acute and Episodic




                             ■ Core primary care services provided in response to an acute or episodic illness or during
       Care




                             a general health assessment (e.g. treatment, consultation, general medication assessment,
                             etc.)


                             Chronic Disease Management Programs
                             A planned approach to care with documented, clear objectives and defined roles for
                             providers, that focuses on maintaining the health of individuals with chronic conditions,
                             delaying progression of their conditions, and preventing complications.
                                   Asthma
                                   COPD
                                   Cardiovascular Disease
                                   Congestive Heart Failure
                                   Hypertension
                                   Diabetes
                                   Mental Health
                                   Other (please specify):
     Planned Care




                             1
                             2
                             3
                             Health Promotion/Disease Prevention Programs
                             A planned approach to care with documented, clear objectives and defined roles for
                             providers, that focuses on preventing diseases from occurring (e.g. screening, education,
                             and counselling).
                                   Periodic Health Exams
                                   Cancer Screening
                                   Immunization (childhood/adult)
                                   Addiction Counselling
                                   Lifestyle and Wellness Counselling
                                   Other (please specify):
                             1
                             2
                             3

                             System Navigation


                             ■ Service coordination & referral to link patients with the appropriate provider /
     Indirect Patient Care




                             organization in the community, including rehabilitation, outpatient & homecare services

                             ■ Assistance with hospital discharge planning
                             ■ Assistance with issues related to determinants of health

                             Interdisciplinary Learning and Collaboration


                             Activities that support interdisciplinary learning, interprofessional consultation, team-
                             building and collaborative practice
                                                                                                                                                                                                                                                             \
                                                                                                                   TOTAL
                             1
                              Target Unattached Patient Enrolment: Enter your target enrolment of patients who previously did not have a physician regularly overseeing their care. This could be patients that do not have family physicians because they have moved to a new community, their family physician has changed communities, retired, passed away, or changed practice type, they have never had a family
                             physician, or enrolled acute care patient previously without a family physician, following the patient’s discharge from an in-patient hospital visit.
                             2
                                 Enter an interdisciplinary health provider (IHP) discipline not included in the previous columns.
                                                                                                                                                                                                                                                                                                                                                                                                                         08/05/08 V2.3
                                                                         Schedule "B"
                                                                            Budget
                                                   [insert name of] Family Health Team, FHT Group #: XXX
                                                                         For the Period
                                                                         April 1, 2XXX
                                                                               to
                                                                       March 31, 2XXX

                                                                     Start Date      Full-Time
                                                                                                                     # Months of
                       Human Resources                                               Equivalent      Annual Salary                     2008-09 Funding
                                                                                                                      Operation
                                                                 (MM DD, YYYY)         (FTE)
                           Column 1                                                                    Column 4                           Column 6
                                                                                                                      Column 5
                                                                     Column 2         Column 3
Management and Administrative Personnel
Executive Director                                                                                                                                   0.00
Administrative Lead                                                                                                                                  0.00
Administrative Lead (small FHT)                                                                                                                      0.00
Finance Manager                                                                                                                                      0.00
Office Administrator / Manager                                                                                                                       0.00
Program Administrator                                                                                                                                0.00
Administrative Assistant                                                                                                                             0.00
Receptionist / Clerical Staff                                                                                                                        0.00
Admin/Support for Blended Salary Model Physician                                                                                                     0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
[Enter Other M or A Staff]                                                                                                                           0.00
Sub-total Management and Admin Salaries                                                       0.00                                 $                 -
Interdisciplinary Providers
Nurse Practitioner                                                                                                                                   0.00
Registered Nurse                                                                                                                                     0.00
Registered Practical Nurse                                                                                                                           0.00
Registered Dietician                                                                                                                                 0.00
Pharmacist                                                                                                                                           0.00
Social Worker                                                                                                                                        0.00
Social Worker (3 yrs. Exp + MSW)                                                                                                                     0.00
Psychological Associate                                                                                                                              0.00
Psychologist                                                                                                                                         0.00
Health Educator/Promoter                                                                                                                             0.00
Mental Health Worker                                                                                                                                 0.00
Chiropodist/Podiatrist                                                                                                                               0.00
Case Worker/Manager                                                                                                                                  0.00
Speech Therapist                                                                                                                                     0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
[Enter Other Interdisciplinary Provider]                                                                                                             0.00
Sub-total Interdisciplinary Provider Salaries                                                 0.00                                 $        08/05/08 -
                                                                                                                                                     V2.3
                                               Start Date       Full-Time
                                                                                                    # Months of
                       Human Resources                          Equivalent          Annual Salary                         2008-09 Funding
                                                                                                     Operation
                                             (MM DD, YYYY)        (FTE)
                            Column 1                                                  Column 4                               Column 6
                                                                                                     Column 5
                                               Column 2          Column 3
Benefits @ 20%                                                                                                        $                 -
Total Salaries & Benefits                                                                                             $                 -
Salaried Physician Personnel 1 :
BSM/Salaried Physician (Level 1)                                                                                                        0.00
BSM/Salaried Physician (Level 2)                                                                                                        0.00
BSM/Salaried Physician (Level 3)                                                                                                        0.00
IS-BSM New Grad/FP without Billing History                                                                                              0.00
IS-BSM 12 Mo. FFS or non-FFS model                                                                                                      0.00
[Enter Other BSM/IS-BSM Physicians]                                                                                                     0.00
[Enter Other BSM/IS-BSM Physicians]                                                                                                     0.00
[Enter Other BSM/IS-BSM Physicians]                                                                                                     0.00
[Enter Other BSM/IS-BSM Physicians]                                                                                                     0.00
[Enter Other BSM/IS-BSM Physicians]                                                                                                     0.00
[Enter Other BSM/IS-BSM Physicians]                                                                                                     0.00
[Enter Other BSM/IS-BSM Physicians]                                                                                                     0.00
[Enter Other BSM/IS-BSM Physicians]                                                                                                     0.00
[Enter Other BSM/IS-BSM Physicians]                                                                                                     0.00
[Enter Other BSM/IS-BSM Physicians]                                                                                                     0.00
Sub-total Physician Salaries                                               0.00                                       $                 -
Physician Locum Allowance                                                                                             $                 -
THAS                                                                                                                  $                 -
Benefits @ 20%                                                                                                        $                 -
Total BSM/Salaried Physician Salaries                                                                                 $                 -
Specialists:                                                 Enter # sessions/yr:
Psychiatrist Sessions                                                                                           n/a                     0.00
Geriatrician sessions                                                                                           n/a                     0.00
Paediatrician Sessions                                                                                          n/a                     0.00
Internist Sessions                                                                                              n/a                     0.00
[Enter Other Specialist]                                                                                        n/a                     0.00
[Enter Other Specialist]                                                                                        n/a                     0.00
[Enter Other Specialist]                                                                                        n/a                     0.00
[Enter Other Specialist]                                                                                        n/a                     0.00
[Enter Other Specialist]                                                                                        n/a                     0.00
[Enter Other Specialist]                                                                                        n/a                     0.00
[Enter Other Specialist]                                                                                        n/a                     0.00
[Enter Other Specialist]                                                                                        n/a                     0.00
[Enter Other Specialist]                                                                                        n/a                     0.00
[Enter Other Specialist]                                                                                        n/a                     0.00
Total Specialist Compensation                                              0.00                                       $                 -
Total Human Resources                                               0.00                                              $                 -




                                                                                                                               08/05/08 V2.3
                                                                              Start Date         Full-Time
                                                                                                                                # Months of
                        Human Resources                                                          Equivalent   Annual Salary                   2008-09 Funding
                                                                                                                                 Operation
                                                                        (MM DD, YYYY)              (FTE)
                             Column 1                                                                           Column 4                         Column 6
                                                                                                                                 Column 5
                                                                              Column 2           Column 3
                                                                                                                                # Months of
                   Other Operational Overhead                                                                     Cost                        2008-09 Funding
                                                                                                                                 Operation
                             Column 1                                         Column 2           Column 3       Column 4                         Column 6
                                                                                                                                 Column 5
Equipment Lease and Service Contracts:
                                                Photocopier Lease       n/a                n/a                                                              0.00
                                         Equipment Leases (specify)     n/a                n/a                                                              0.00
                                         Equipment Leases (specify)     n/a                n/a                                                              0.00
                                         Equipment Leases (specify)     n/a                n/a                                                              0.00
                                         Equipment Leases (specify)     n/a                n/a                                                              0.00
                                         Equipment Leases (specify)     n/a                n/a                                                              0.00
                                         Equipment Leases (specify)     n/a                n/a                                                              0.00
                                         Equipment Leases (specify)     n/a                n/a                                                              0.00
                                         Equipment Leases (specify)     n/a                n/a                                                              0.00
                                         Equipment Leases (specify)     n/a                n/a                                                              0.00
                                         Equipment Leases (specify)     n/a                n/a                                                              0.00

                               Equipment Service Contract (specify)     n/a                n/a                                                              0.00
                               Equipment Service Contract (specify)     n/a                n/a                                                              0.00
                               Equipment Service Contract (specify)     n/a                n/a                                                              0.00
                               Equipment Service Contract (specify)     n/a                n/a                                                              0.00
                               Equipment Service Contract (specify)     n/a                n/a                                                              0.00
                               Equipment Service Contract (specify)     n/a                n/a                                                              0.00
                               Equipment Service Contract (specify)     n/a                n/a                                                              0.00
                               Equipment Service Contract (specify)     n/a                n/a                                                              0.00
                               Equipment Service Contract (specify)     n/a                n/a                                                              0.00
                               Equipment Service Contract (specify)     n/a                n/a                                                              0.00
Sub-Total Equipment Lease and Service Contracts                                                                          0.00                               0.00
General Overhead
                                                          Advertising   n/a                n/a                                                              0.00
                                                    Medical Supplies    n/a                n/a                                                              0.00
                                           Communication Materials      n/a                n/a                                                              0.00
              Cell Phone/Wireless Handheld/Telephone Line/Service       n/a                n/a                                                              0.00
                                  FHT Association Membership Fees       n/a                n/a                                                              0.00
                        Stationary/Printing/Copying/Postage/Courier     n/a                n/a                                                              0.00
                                                      Office Supplies   n/a                n/a                                                              0.00
                                                      Medical Waste     n/a                n/a                                                              0.00
                                                    Library Materials   n/a                n/a                                                              0.00
                                             Payroll Service Contract   n/a                n/a                                                              0.00
                                                          Translation   n/a                n/a                                                              0.00
                                              Other (please describe)   n/a                n/a                                                              0.00
                                              Other (please describe)   n/a                n/a                                                              0.00
                                              Other (please describe)   n/a                n/a                                                              0.00
                                              Other (please describe)   n/a                n/a                                                              0.00
                                              Other (please describe)   n/a                n/a                                                              0.00
                                              Other (please describe)   n/a                n/a                                                              0.00
                                              Other (please describe)   n/a                n/a                                                              0.00
                                              Other (please describe)   n/a                n/a                                                              0.00
                                              Other (please describe)   n/a                n/a                                                              0.00
                                              Other (please describe)   n/a                n/a                                                              0.00
Sub-Total General Overhead                                                                                               0.00                               0.00
Information Technology Other Operational Overhead
                                      IT Hardware (Annual Ongoing)      n/a                n/a                                                              0.00
                                       IT Software (Annual Ongoing)     n/a                n/a                                                              0.00
                   Other IT Costs - Please Specify (Annual/Ongoing)     n/a                n/a                                                              0.00
                   Other IT Costs - Please Specify (Annual/Ongoing)     n/a                n/a                                                              0.00
                   Other IT Costs - Please Specify (Annual/Ongoing)     n/a                n/a                                                              0.00
                   Other IT Costs - Please Specify (Annual/Ongoing)     n/a                n/a                                                              0.00
                   Other IT Costs - Please Specify (Annual/Ongoing)     n/a                n/a                                                              0.00
                   Other IT Costs - Please Specify (Annual/Ongoing)     n/a                n/a                                                              0.00
                   Other IT Costs - Please Specify (Annual/Ongoing)     n/a                n/a                                                              0.00
                   Other IT Costs - Please Specify (Annual/Ongoing)     n/a                n/a                                                              0.00
                   Other IT Costs - Please Specify (Annual/Ongoing)     n/a                n/a                                                              0.00
                   Other IT Costs - Please Specify (Annual/Ongoing)     n/a                n/a                                                              0.00
Sub-Total IT Ongoing Overhead                                                                                            0.00                               0.00
Travel                                                                  n/a                n/a                                                              0.00
Professional Development                                                n/a                n/a                                                              0.00
Audit                                                                   n/a                n/a                                                              0.00
Legal                                                                   n/a                n/a                                                              0.00
General Consulting                                                      n/a                n/a                                                              0.00
Recruitment                                                             n/a                n/a                                                              0.00
Physician Consulting                                                    n/a                n/a                                                              0.00
Rent                                                                    n/a                n/a                                                              0.00
Property tax and Utilities                                              n/a                n/a                                                              0.00
Common Area Maintenance                                                 n/a                n/a                                                              0.00
                                                                                                                                                   08/05/08 V2.3
                                                                          Start Date          Full-Time
                                                                                                                              # Months of
                        Human Resources                                                       Equivalent   Annual Salary                          2008-09 Funding
                                                                                                                               Operation
                                                                    (MM DD, YYYY)               (FTE)
                            Column 1                                                                             Column 4                            Column 6
                                                                                                                                  Column 5
                                                                          Column 2            Column 3
Security System                                                     n/a                 n/a                                                                      0.00
Insurance                                                           n/a                 n/a                                                                      0.00
Program Development Consulting                                      n/a                 n/a                                                                      0.00
Other Overhead (please describe)                                    n/a                 n/a                                                                      0.00
Other Overhead (please describe)                                    n/a                 n/a                                                                      0.00
Other Overhead (please describe)                                    n/a                 n/a                                                                      0.00
Other Overhead (please describe)                                    n/a                 n/a                                                                      0.00
Other Overhead (please describe)                                    n/a                 n/a                                                                      0.00
Other Overhead (please describe)                                    n/a                 n/a                                                                      0.00
Other Overhead (please describe)                                    n/a                 n/a                                                                      0.00
Other Overhead (please describe)                                    n/a                 n/a                                                                      0.00
Other Overhead (please describe)                                    n/a                 n/a                                                                      0.00
Other Overhead (please describe)                                    n/a                 n/a                                                                      0.00
Total Other Overhead Costs                                                                                                                                      0.00


                                                                                                                                                  2008-09 Funding
                       One-Time Funding


                                                                                                                                                     Column 6
                            Column 1                                      Column 2            Column 3           Column 4         Column 5
Office Furnishings                                                  n/a                 n/a                n/a              n/a                                   0.00
Clinical Equipment                                                  n/a                 n/a                n/a              n/a                                   0.00
One-Time IT Hardware                                                n/a                 n/a                n/a              n/a                                   0.00
One-Time IT Software                                                n/a                 n/a                n/a              n/a                                   0.00
Signage                                                             n/a                 n/a                n/a              n/a                                   0.00
One-Time Telecommunications                                         n/a                 n/a                n/a              n/a                                   0.00
Moving Costs                                                        n/a                 n/a                n/a              n/a                                   0.00
Other One-Time (please describe)                                    n/a                 n/a                n/a              n/a                                   0.00
Other One-Time (please describe)                                    n/a                 n/a                n/a              n/a                                   0.00
Other One-Time (please describe)                                    n/a                 n/a                n/a              n/a                                   0.00
Other One-Time (please describe)                                    n/a                 n/a                n/a              n/a                                   0.00
Other One-Time (please describe)                                    n/a                 n/a                n/a              n/a                                   0.00
Other One-Time (please describe)                                    n/a                 n/a                n/a              n/a                                   0.00
Other One-Time (please describe)                                    n/a                 n/a                n/a              n/a                                   0.00
Other One-Time (please describe)                                    n/a                 n/a                n/a              n/a                                   0.00
Other One-Time (please describe)                                    n/a                 n/a                n/a              n/a                                   0.00
Other One-Time (please describe)                                    n/a                 n/a                n/a              n/a                                   0.00
Total Start Up/One-Time Costs                                                                                                                 $                   -

Totals                                                                                                                                       $                        -

Total less BSM/Salaried Physicians1                                                                                                           $                   -


1 Amounts for physicians compensated through the Blended Salary Model [(BSM), inclusive of salary, benefits, locum, and THAS] are an estimate, as they are made
separately from this agreement and vary based on physician enrolment level and/or on the number of physicians hired. However, actual expenditures for BSM and
Income Stablization-BSM physicians must be reported in quarterly financial reports and the Statement of Revenues and Expenditures.




                                                                                                                                                       08/05/08 V2.3
                                             Schedule "B"
                              Appendix 1 - Furnishings, Equipment, and IT
                       [insert name of] Family Health Team, FHT Group #: XXX
                                             For the Period
                                             April 1, 2XXX
                                                   to
                                            March 31, 2XXX

                                        1
                            Categories                                         2008-09 Funding

                             Column 1                                             Column 2
Office Furnishings




                                             Delivery/Shipping & Handling                        0.00
                                                                 Assembly                        0.00
                                                                      GST                        0.00
                                                                      PST                        0.00
                                                  Office Furnishings Total                       0.00
Clinical Equipment




                                             Delivery/Shipping & Handling
                                                                 Assembly
                                                                     GST                         0.00
                                                 Clinical Equipment Total                        0.00
One-Time IT Hardware




                                                             Configuration
                                                               Installation
                                             Delivery/Shipping & Handling
                                                                 Assembly
                                                                       GST                       0.00
                                                                       PST                       0.00
                                             One-Time IT Hardware Total                          0.00
One-Time IT Software




                                                                                                  08/05/08 V2.3
                                                  1
                                      Categories                                                  2008-09 Funding

                                       Column 1                                                       Column 2

                                                                          Configuration
                                                                            Installation
                                                          Delivery/Shipping & Handling
                                                                               Assembly
                                                                                    GST                                   0.00
                                                                                    PST                                   0.00
                                                           One-Time IT Software Total                                     0.00

1 The approved furnishings, equipment and IT are detailed above. The sub-totals roll up automatically into Schedule B -
Budget.




                                                                                                                           08/05/08 V2.3
                                               Schedule "C"
                                             Payment Schedule
                         [insert name of] Family Health Team, FHT Group #: XXX
                                               For the Period
                                               April 1, 2XXX
                                                     to
                                             March 31, 2XXX

The Ministry has granted to the “Recipient”               $                                                     -
                                               1
for the implementation of the Plan. This amount will be deposited in:
                                                  Bank: [Insert Bank Name]
                                               Address: [Insert Bank Address]
                                        Account Name: [Insert Account Name]
                              Branch Transit Number: [Insert Transit Number]
                                   Institution Number: [Insert Institution Number]
                                     Account Number: [Insert Account Number]
The payment amount for the Plan will be allocated as follows:
                                Total Funding Amount $                                                      -
             Less Unused Funds Offset (please specify)
             Less Unused Funds Offset (please specify)
             Less Unused Funds Offset (please specify)
             Less Unused Funds Offset (please specify)
                               Total Payment Amount $                                                       -

                           Date                                                   Payment2
            Last business day of April, 20XX                     $                                                  -
             Last business day of May, 20XX                      $                                                  -
             Last business day of June, 20XX                     $                                                  -
             Last business day of July, 20XX                     $                                                  -
           Last business day of August, 20XX                     $                                                  -
          Last business day of September, 20XX                   $                                                  -
           Last business day of October, 20XX                    $                                                  -
          Last business day of November, 20XX                    $                                                  -
          Last business day of December, 20XX                    $                                                  -
           Last business day of January, 20XX                    $                                                  -
          Last business day of February, 20XX                    $                                                  -
            Last business day of March, 20XX                     $                                                  -
                      TOTAL PAID                                 $                                                  -
1
 Payments for physicians compensated through the Blended Salary Model [(BSM), which includes salary,
benefits, locum, and THAS] are excluded from this payment schedule as they are made separately from this
agreement and vary based on physician enrolment level and/or on the number of physicians hired. Actual
expenditures for BSM physicians must be reported in quarterly financial reports and the Statement of Revenues
and Expenditures.

Similarly, payments to physicians compensated through Income Stabilization-Blended Salary Model (IS-BSM)
are excluded from this payment schedule as they are made separately. Actual expenditures for IS-BSM must be
reported in quarterly financial reports and the Statement of Revenues and Expenditures.
2
  The ministry may adjust the payments listed in this column

The Recipient is required to deposit the funding amount into this specified account immediately upon the receipt
of the funds, and must report back to the Ministry of the deposit date. This is the date the Ministry
acknowledges as the date the funding begins to bear interest.

The funding will cover expenditures incurred between [Insert Start Date] to [Insert End Date] or upon
completion of the Plan, or the termination of this agreement, whichever occurs first.




                                                                                                                        08/05/08 V2.3
                                                 FAMILY HEALTH TEAMS

                                    INSTRUCTIONS FOR REPORTING SCHEDULES

This sheet contains instructions to aid Family Health Teams in completing reports as specified in the agreement between your
Family Health Team and the Ministry of Health and Long-Term Care.

Schedule "D" - Appendix 1 - Reporting Schedule

This schedule specifies the reports that are due and their respective due dates.

Schedule "D" - Appendix 2 - Quarterly Reports and Appendix 3 - Statement of Revenues and Expenses

The quarterly financial report is due at the end of each fiscal quarter and expenses to date, and variances from the budget as
specified in the agreement. The Statement of Revenues and Expenses is the year-end summary of revenues (FHT funding and
other, which the FHT should specify) and actual funding expended by the FHT. The Statement of Revenues and Expenses
must be completed and provided to an accounting professional, licensed under the Public Accountancy Act for the purpose of
completing an audit.

Budget Categories and Approved Budget - Please ensure that the first two columns are a duplicate of Schedule “B” (the
budget). This includes using the same FTE number.
Note:
- Don’t prorate this amount; use the same figure as in the budget.
- If the term of the agreement commences later than April 1 (e.g. June 1) and there are follow-on amendments, then the
“Approved Budget” will be the sum of the expense item in each of the amendments.
Actual Year-To-Date (YTD) Expenditure - Enter the amount of actual expenditure for each budget line for the "year-to-date"
current fiscal year, i.e., from April 1st to the end of the current reporting period. The “actual expenditure” includes bills paid
as well as expenditure commitments generated (i.e., accrued expenditures).
Forecast to End of Current Fiscal Year - Enter an estimate of the future months’ expenditures to the end of the current fiscal
year (March 31). This column will be used for internal Ministry planning purposes. This column does not appear in the
Statement of Revenues and Expenses.
Total Forecast - The total forecast is the addition of the Actual YTD Expenditure column and the Forecast to the End of the
Current Fiscal Year. This column does not appear in the Statement of Revenues and Expenses.
Variance (Overspending)/Underspending - The variance is equal to the difference between the Approved Budget Allocation
and the Total Forecast.
Variance Explanation/Comments - Enter information to explain or comment on the variance in Column 6.
 “Totals” - The amount on this line under the column “Approved Budget” should be the same amount as the total grant in the
agreement (inclusive of any amendments).
Interest accrued from […] to […]” - Unused grant funds should be earning interest. Enter the amount of interest
accumulated from the date the grant was deposited to the end of the current quarter.
 “Amount recoverable by the Ministry” - This amount includes unused grant funds reported by the FHT’s auditor plus
interest earned to date.
“I certify….” - The Quarterly Financial Report should be signed by the individual(s) with authority to bind the FHT.
Quarterly financial reports must be received every three months. Do not wait until the end of the term to submit this
Be sure to include the following on your quarterly financial report:
- the name of your FHT,
- the start date of the pertinent agreement, and
- the fiscal year's start date, and the quarter’s end date.
The Quarterly Financial Report is NOT an Auditor’s Report. The Statement of Revenues and Expenses must be completed
and provided to an auditor for the purpose of the final audit.
If additional rows are needed to add more line items, please unhide them from the bottom of the category.




                                                                                                                      08/05/08 V2.3
                                                  FAMILY HEALTH TEAMS

                               INSTRUCTIONS FOR REPORTING SCHEDULES
Schedule "D" - Appendix 4 - Programs and Services Quarterly Reports

This report gives an account of the programs and services provided by Interdisciplinary Health Professionals (IHP) and the
total number of patient visits by discipline for acute and episodic care services and planned care programs in each fiscal
quarter.

Health Professional Group - Enter the interdisciplinary provider discipline (e.g. nurse practitioner, dietitian, social worker,
etc.). One quarterly report is to be submitted for each discipline, not by each individual provider.
Total FTE - Enter the total number of FTEs for the reporting discipline. The total number of FTEs may differ from the total
number of providers in each discipline if some of these providers work on a part-time basis.
For each of the following categories and sub-categories, please identify the programs provided by specifying the number of
patient visits for the reporting provider group over the reporting period. Entries should only be recorded for the health care
activity that reflects the primary purpose for the patient's visit. A patient visit may be recorded multiple times if a patient is
seen on more than one occasion. Each participant in a group session should be counted as a separate patient visit.
Acute & Episodic Care
▪ Please record the total number of patient visits for all Acute and Episodic Care Services that your IHP group provided
during the reporting period.
Planned Care Programs - Chronic Disease Management / Health Promotion & Disease Prevention
▪ Please select the specific Chronic Disease Management program(s) that your IHP group participated in over the reporting
period and record the total number of patient visits for each program.
▪ If your provider group participated in a program that is not part of the programs that are listed, please select "Other" and
specify the program that was provided.
▪ If your provider group is not participating in specific programs, or your FHT has not yet developed planned care programs,
this section should be left blank.
▪ 'Total visits' calculate automatically if you are entering data in the Excel spreadsheet. If you are entering data manually
please record the total visits for CDM and/or HPDP programs managed by your IHP group over the reporting period.
Indirect Patient Care - System Navigation
▪ Please indicate whether your IHP group participated in any system navigation services during the reporting period. If they
did participate, please indicate the number of FTEs in your group who participated in system navigation activities. Of those
that participated in system navigation, please record the number of FTEs in your IHP group who spent more than 50% of their
workload on system navigation activities.
Indirect Patient Care - Interdisciplinary Learning and Collaboration
▪ Please record the average frequency (i.e. weekly, bi-weekly, monthly, or as needed) that your IHP group spent on activities
such as interdisciplinary learning, interprofessional consultation, and team-building.

Schedule "D" - Appendix 5 - Physician Consulting Quarterly Reports

This report is completed for each fiscal quarter to give an account on the activities of the physician consultant(s), which may
include, for example, program development, implementation and evaluation.

Name of Physician Consultant(s) - Enter the name of the physician consultant(s). One report is to be entered per FHT, even if
there are more than one physician consultants.
Eligible Activities - the activities listed in the template are eligible physician consulting activities. You may enter other
activities if you choose. Please record the total hours / quarter you spent on each activity in the space provided.
Hours / Quarter - refers to the total number of hours in the quarter that the reporting Physician Leader spent on each of the
eligible activities. If you have not spent any hours / quarter on any one of the eligible activities please record "N/A" in the
space provided.
Conditions:
- Each entry into this template must represent a separate block of time (e.g. minimum of 1 hour)
- Recorded time must not be for clinical patient contact
- Recorded time must not be for other MD leader functions
- For physicians remunerated under the complement-based (RNPGA) or blended salary models, consulting time must be in
addition to the time for which you are already compensated



                                                                                                                        08/05/08 V2.3
                                                FAMILY HEALTH TEAMS

                               INSTRUCTIONS FOR REPORTING SCHEDULES
Schedule "D" - Appendix 6 - Hiring Status Report Quarterly Reports

The quarterly IHP hiring report is due at the end of each fiscal quarter and reports on IHP recruitment, retention, and attrition
in each FHT.

Approved FTEs - this column includes the type(s) of Health Professional Disciplines approved based on the business and
operational plan submitted. This does not include conditionally approved FTEs.
Hired FTEs - this column includes the actual number of hired FTEs per IHP discipline based on your records as of the
"Reporting Date", e.g., March 31, 2008.
Vacant FTEs - this column includes the actual number of vacant FTEs per IHP discipline based on your records as of the
"Reporting Date", e.g., March 31, 2008 (it's calculated: "approved" less "Hired").
Estimated/Actual Hire Date - this column reports on estimated dates all vacant FTEs per IHP discipline will be hired by the
Family Health Team. If the FTE has already been hired, please insert the actual hire date.
Comments - please provide brief description of your Team's recruitment plan.

Annual Report

In the annual report, FHTs are required to provide a narrative report that reflects the Family Health Team’s progress to
achieving the goals set out in the business plan and include the Team’s achievements to date, including success in reaching
roster targets, any programs that have been implemented or are in light of commitments in the business plan, the role of
interdisciplinary providers in program delivery, progress in capital or IT initiatives, new linkages forged with community
organizations and/or academic institutions, and/or any other significant accomplishments achieved over the course of the year.
Minimum requirements will be set out in the agreement.




                                                                                                                     08/05/08 V2.3
                                                           Schedule "D"
                                                  Appendix 1 - Report Due Dates
                                     [insert name of] Family Health Team, FHT Group #: XXX
                                                           For the Period
                                                           April 1, 2XXX
                                                                 to
                                                         March 31, 2XXX

                                                                                   Due Date
                 Report Due                            Q1                Q2                    Q3                    Q4
           Quarterly Financial Report            July 31, 2XXX    October 31, 2XXX      January 31, 2XXX      April 30, 2XXX
     Quarterly Program and Service Report        July 31, 2XXX    October 31, 2XXX      January 31, 2XXX      April 30, 2XXX
     Quarterly Physician Consulting Report       July 31, 2XXX    October 31, 2XXX      January 31, 2XXX      April 30, 2XXX
          Quarterly IHP Status Report            July 31, 2XXX    October 31, 2XXX      January 31, 2XXX      April 30, 2XXX
              FHT Annual Report                                                 May 31, 2XXX
Audited Statement of Revenues and Expenditures                                  May 31, 2XXX




                                                                                                           08/05/08 V2.3
                                                                                        Schedule "D"
                                                                           Appendix 2 - Financial Quarterly Report
                                                                  [insert name of] Family Health Team, FHT Group #: XXX
                                                                                        For the Period
                                                                                        April 1, 2XXX
                                                                                              to
                                                                                       June 30, 2XXX


                                                                             Actual                                                     Variance
                                                       Approved                            Forecast to End of
               Budget Categories                                               Q1                                   Total Forecast   (Overspending)/           Variance Explanation/
                                                        Budget1                             Current Fiscal
                                                                           Expenditure                                               Underspending3                 Comments
                                                                                                 Year2
                                                                                                                (Col. 3 + Col. 4)
                                                                            Column 3                               Column 5              (Col. 2 - Col. 5)          Column 7
                                                       Column 2                                Column 4
                      Column 1                                                                                                             Column 6
                 Human Resources
Management and Administrative Personnel
Executive Director                                                0.00                                                          0.00                    0.00
Administrative Lead                                               0.00                                                          0.00                    0.00
Administrative Lead (small FHT)                                   0.00                                                          0.00                    0.00
Finance Manager                                                   0.00                                                          0.00                    0.00
Office Administrator / Manager                                    0.00                                                          0.00                    0.00
Program Administrator                                             0.00                                                          0.00                    0.00
Administrative Assistant                                          0.00                                                          0.00                    0.00
Receptionist / Clerical Staff                                     0.00                                                          0.00                    0.00
Admin/Support for Blended Salary Model Physician                  0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
[Enter Other M or A Staff]                                        0.00                                                          0.00                    0.00
Sub-total Management and Admin Salaries            $              -    $               -   $              -     $               -    $                  -
Interdisciplinary Providers                                                                                                                                         08/05/08 V2.3
                                                                           Actual                                                       Variance
                                                    Approved                             Forecast to End of
               Budget Categories                            1                Q1                                   Total Forecast     (Overspending)/         Variance Explanation/
                                                     Budget                               Current Fiscal                                           3
                                                                         Expenditure                2                                Underspending                Comments
                                                                                               Year
                                                                                                              (Col. 3 + Col. 4)
                                                                          Column 3                               Column 5              (Col. 2 - Col. 5)          Column 7
                                                    Column 2                                 Column 4
                     Column 1                                                                                                            Column 6
                 Human Resources
Nurse Practitioner                                              0.00                                                          0.00                    0.00
Registered Nurse                                                0.00                                                          0.00                    0.00
Registered Practical Nurse                                      0.00                                                          0.00                    0.00
Registered Dietician                                            0.00                                                          0.00                    0.00
Pharmacist                                                      0.00                                                          0.00                    0.00
Social Worker                                                   0.00                                                          0.00                    0.00
Social Worker (3 yrs. Exp + MSW)                                0.00                                                          0.00                    0.00
Psychological Associate                                         0.00                                                          0.00                    0.00
Psychologist                                                    0.00                                                          0.00                    0.00
Health Educator/Promoter                                        0.00                                                          0.00                    0.00
Mental Health Worker                                            0.00                                                          0.00                    0.00
Chiropodist/Podiatrist                                          0.00                                                          0.00                    0.00
Case Worker/Manager                                             0.00                                                          0.00                    0.00
Speech Therapist                                                0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
[Enter Other Interdisciplinary Provider]                        0.00                                                          0.00                    0.00
Sub-total Interdisciplinary Provider Salaries   $               -    $               -   $              -     $               -    $                  -
Benefits @ 20%                                  $               -                        $              -     $               -    $                  -
Total Salaries & Benefits                       $               -    $               -   $              -     $               -    $                  -
Salaried Physician Personnel:
BSM/Salaried Physician (Level 1)                                0.00                                                          0.00                    0.00
BSM/Salaried Physician (Level 2)                                0.00                                                          0.00                    0.00
BSM/Salaried Physician (Level 3)                                0.00                                                          0.00                    0.00        08/05/08 V2.3
                                                                                   Actual                                                       Variance
                                                          Approved                               Forecast to End of
                Budget Categories                                 1                  Q1                                   Total Forecast     (Overspending)/           Variance Explanation/
                                                           Budget                                 Current Fiscal                                           3
                                                                                 Expenditure                2                                Underspending                  Comments
                                                                                                       Year
                                                                                                                      (Col. 3 + Col. 4)
                                                                                  Column 3                               Column 5                (Col. 2 - Col. 5)          Column 7
                                                          Column 2                                   Column 4
                      Column 1                                                                                                                     Column 6
                 Human Resources
IS-BSM New Grad/FP without Billing History                            0.00                                                            0.00                      0.00
IS-BSM 12 Mo. FFS or non-FFS model                                    0.00                                                            0.00                      0.00
[Enter Other BSM/IS-BSM Physicians]                                   0.00                                                            0.00                      0.00
[Enter Other BSM/IS-BSM Physicians]                                   0.00                                                            0.00                      0.00
[Enter Other BSM/IS-BSM Physicians]                                   0.00                                                            0.00                      0.00
[Enter Other BSM/IS-BSM Physicians]                                   0.00                                                            0.00                      0.00
[Enter Other BSM/IS-BSM Physicians]                                   0.00                                                            0.00                      0.00
[Enter Other BSM/IS-BSM Physicians]                                   0.00                                                            0.00                      0.00
[Enter Other BSM/IS-BSM Physicians]                                   0.00                                                            0.00                      0.00
[Enter Other BSM/IS-BSM Physicians]                                   0.00                                                            0.00                      0.00
[Enter Other BSM/IS-BSM Physicians]                                   0.00                                                            0.00                      0.00
[Enter Other BSM/IS-BSM Physicians]                                   0.00                                                            0.00                      0.00
Sub-Total Physician Salaries                          $               -      $               -   $              -     $               -      $                  -
Sub-Total Physician Locum Allowance                   $               -      $               -   $              -     $               -      $                  -
THAS                                                  $               -      $               -   $              -     $               -      $                  -
Benefits @ 20%                                        $               -      $               -   $              -     $               -      $                  -
Total BSM/Salaried Physician Salaries                 $               -      $               -   $              -     $               -      $                  -
Specialists:
Psychiatrist Sessions                                                 0.00                                                            0.00                      0.00
Geriatrician sessions                                                 0.00                                                            0.00                      0.00
Paediatrician Sessions                                                0.00                                                            0.00                      0.00
Internist Sessions                                                    0.00                                                            0.00                      0.00
[Enter Other Specialist]                                              0.00                                                            0.00                      0.00
[Enter Other Specialist]                                              0.00                                                            0.00                      0.00
[Enter Other Specialist]                                              0.00                                                            0.00                      0.00
[Enter Other Specialist]                                              0.00                                                            0.00                      0.00
[Enter Other Specialist]                                              0.00                                                            0.00                      0.00
[Enter Other Specialist]                                              0.00                                                            0.00                      0.00
[Enter Other Specialist]                                              0.00                                                            0.00                      0.00
[Enter Other Specialist]                                              0.00                                                            0.00                      0.00
[Enter Other Specialist]                                              0.00                                                            0.00                      0.00
[Enter Other Specialist]                                              0.00                                                            0.00                      0.00
Total Specialist Compensation                         $               -    $                 -   $              -     $               -    $                    -
Total Human Resources                                 $               -    $                 -   $              -     $               -    $                    -
                   Other Overhead
Equipment Lease and Service Contracts:
                                Photocopier Lease                     0.00                                                            0.00                      0.00
                         Equipment Leases (specify)                   0.00                                                            0.00                      0.00
                         Equipment Leases (specify)                   0.00                                                            0.00                      0.00
                         Equipment Leases (specify)                   0.00                                                            0.00                      0.00
                         Equipment Leases (specify)                   0.00                                                            0.00                      0.00        08/05/08 V2.3
                                                                              Actual                                                         Variance
                                                         Approved                              Forecast to End of
                 Budget Categories                               1              Q1                                   Total Forecast       (Overspending)/       Variance Explanation/
                                                          Budget                                Current Fiscal                                          3
                                                                            Expenditure                   2                               Underspending              Comments
                                                                                                     Year
                                                                                                                     (Col. 3 + Col. 4)
                                                                             Column 3                                   Column 5          (Col. 2 - Col. 5)          Column 7
                                                         Column 2                                  Column 4
                       Column 1                                                                                                             Column 6
                   Human Resources
                           Equipment Leases (specify)                0.00                                                          0.00                  0.00
                           Equipment Leases (specify)                0.00                                                          0.00                  0.00
                           Equipment Leases (specify)                0.00                                                          0.00                  0.00
                           Equipment Leases (specify)                0.00                                                          0.00                  0.00
                           Equipment Leases (specify)                0.00                                                          0.00                  0.00
                           Equipment Leases (specify)                0.00                                                          0.00                  0.00
                 Equipment Service Contract (specify)                0.00                                                          0.00                  0.00
                 Equipment Service Contract (specify)                0.00                                                          0.00                  0.00
                 Equipment Service Contract (specify)                0.00                                                          0.00                  0.00
                 Equipment Service Contract (specify)                0.00                                                          0.00                  0.00
                 Equipment Service Contract (specify)                0.00                                                          0.00                  0.00
                 Equipment Service Contract (specify)                0.00                                                          0.00                  0.00
                 Equipment Service Contract (specify)                0.00                                                          0.00                  0.00
                 Equipment Service Contract (specify)                0.00                                                          0.00                  0.00
                 Equipment Service Contract (specify)                0.00                                                          0.00                  0.00
                 Equipment Service Contract (specify)                0.00                                                          0.00                  0.00
  Sub-Total Equipment Lease and Service Contracts                    0.00               0.00                  0.00                 0.00                  0.00
  General Overhead4
                                           Advertising               0.00                                                          0.00                  0.00
                                     Medical Supplies                0.00                                                          0.00                  0.00
                            Communication Materials                  0.00                                                          0.00                  0.00
Cell Phone/Wireless Handheld/Telephone Line/Service                  0.00                                                          0.00                  0.00
                   FHT Association Membership Fees                   0.00                                                          0.00                  0.00
          Stationary/Printing/Copying/Postage/Courier                0.00                                                          0.00                  0.00
                                       Office Supplies               0.00                                                          0.00                  0.00
                                       Medical Waste                 0.00                                                          0.00                  0.00
                                     Library Materials               0.00                                                          0.00                  0.00
                              Payroll Service Contract               0.00                                                          0.00                  0.00
                                           Translation               0.00                                                          0.00                  0.00
                               Other (please describe)               0.00                                                          0.00                  0.00
                               Other (please describe)               0.00                                                          0.00                  0.00
                               Other (please describe)               0.00                                                          0.00                  0.00
                               Other (please describe)               0.00                                                          0.00                  0.00
                               Other (please describe)               0.00                                                          0.00                  0.00
                               Other (please describe)               0.00                                                          0.00                  0.00
                               Other (please describe)               0.00                                                          0.00                  0.00
                               Other (please describe)               0.00                                                          0.00                  0.00
                               Other (please describe)               0.00                                                          0.00                  0.00
                               Other (please describe)               0.00                                                          0.00                  0.00
  Sub-Total General Overhead                                         0.00               0.00                  0.00                 0.00                  0.00
  Information Technology Other Operational Overhead                                                                                                                  08/05/08 V2.3
                                                                          Actual                                                         Variance
                                                     Approved                              Forecast to End of
               Budget Categories                             1              Q1                                   Total Forecast       (Overspending)/       Variance Explanation/
                                                      Budget                                Current Fiscal                                          3
                                                                        Expenditure                   2                               Underspending              Comments
                                                                                                 Year
                                                                                                                 (Col. 3 + Col. 4)
                                                                         Column 3                                   Column 5          (Col. 2 - Col. 5)          Column 7
                                                     Column 2                                  Column 4
                     Column 1                                                                                                           Column 6
                Human Resources
                     IT Hardware (Annual Ongoing)                0.00                                                          0.00                  0.00
                      IT Software (Annual Ongoing)               0.00                                                          0.00                  0.00
  Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                                          0.00                  0.00
  Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                                          0.00                  0.00
  Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                                          0.00                  0.00
  Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                                          0.00                  0.00
  Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                                          0.00                  0.00
  Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                                          0.00                  0.00
  Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                                          0.00                  0.00
  Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                                          0.00                  0.00
  Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                                          0.00                  0.00
  Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                                          0.00                  0.00
Sub-Total IT Ongoing Overhead                                    0.00               0.00                  0.00                 0.00                  0.00
Travel                                                           0.00                                                          0.00                  0.00
Professional Development                                         0.00                                                          0.00                  0.00
Audit                                                            0.00                                                          0.00                  0.00
Legal                                                            0.00                                                          0.00                  0.00
General Consulting                                               0.00                                                          0.00                  0.00
Recruitment                                                      0.00                                                          0.00                  0.00
Physician Consulting                                             0.00                                                          0.00                  0.00
Rent                                                             0.00                                                          0.00                  0.00
Property tax and Utilities                                       0.00                                                          0.00                  0.00
Common Area Maintenance                                          0.00                                                          0.00                  0.00
Security System                                                  0.00                                                          0.00                  0.00
Insurance                                                        0.00                                                          0.00                  0.00
Program Development Consulting                                   0.00                                                          0.00                  0.00
Other Overhead (please describe)                                 0.00                                                          0.00                  0.00
Other Overhead (please describe)                                 0.00                                                          0.00                  0.00
Other Overhead (please describe)                                 0.00                                                          0.00                  0.00
Other Overhead (please describe)                                 0.00                                                          0.00                  0.00
Other Overhead (please describe)                                 0.00                                                          0.00                  0.00
Other Overhead (please describe)                                 0.00                                                          0.00                  0.00
Other Overhead (please describe)                                 0.00                                                          0.00                  0.00
Other Overhead (please describe)                                 0.00                                                          0.00                  0.00
Other Overhead (please describe)                                 0.00                                                          0.00                  0.00
Other Overhead (please describe)                                 0.00                                                          0.00                  0.00
Total Other Overhead Costs                                       0.00               0.00                  0.00                 0.00                  0.00
                 One-Time Costs
Office Furnishings                                               0.00                                                          0.00                  0.00
Clinical Equipment                                               0.00                                                          0.00                  0.00
One-Time IT Hardware                                             0.00                                                          0.00                  0.00        08/05/08 V2.3
                                                                                    Actual                                                                     Variance
                                                             Approved                                   Forecast to End of
                 Budget Categories                                   1                Q1                                           Total Forecast           (Overspending)/              Variance Explanation/
                                                              Budget                                     Current Fiscal                                                   3
                                                                                  Expenditure                      2                                        Underspending                     Comments
                                                                                                              Year
                                                                                                                                   (Col. 3 + Col. 4)
                                                                                    Column 3                                          Column 5              (Col. 2 - Col. 5)                 Column 7
                                                             Column 2                                       Column 4
                   Column 1                                                                                                                                   Column 6
               Human Resources
One-Time IT Software                                                     0.00                                                                    0.00                      0.00
Signage                                                                  0.00                                                                    0.00                      0.00
One-Time Telecommunications                                              0.00                                                                    0.00                      0.00
Moving Costs                                                             0.00                                                                    0.00                      0.00
Other One-Time (please describe)                                         0.00                                                                    0.00                      0.00
Other One-Time (please describe)                                         0.00                                                                    0.00                      0.00
Other One-Time (please describe)                                         0.00                                                                    0.00                      0.00
Other One-Time (please describe)                                         0.00                                                                    0.00                      0.00
Other One-Time (please describe)                                         0.00                                                                    0.00                      0.00
Other One-Time (please describe)                                         0.00                                                                    0.00                      0.00
Other One-Time (please describe)                                         0.00                                                                    0.00                      0.00
Other One-Time (please describe)                                         0.00                                                                    0.00                      0.00
Other One-Time (please describe)                                         0.00                                                                    0.00                      0.00
Other One-Time (please describe)                                         0.00                                                                    0.00                      0.00
Total Start Up/One-Time Costs                           $                -    $                 -       $              -       $                 -    $                    -

Totals                                               $               - $                            -   $                  -   $                    -   $                      -
Interest Rate in Interest-bearing account (e.g.; 3.00%)
Interest accrued from [Date of funds deposited] to [insert end of funding period]                                                                       $                  -
Amount recoverable by the Ministry                                                                                                                      $                  -

1 As defined in Schedule B of the Interim Funding Agreement
2 Estimate of total expenditures incurred from end of this reporting period to the end of the current fiscal year (e.g. March 31, 2008)
3 Approved Budget Allocation minus the Total Forecast.
4 General Overhead expenditures must be reported on in detail as per the sub-categories (e.g. medical supplies, payroll service contract).

I certify that this is an accurate account of expenditures for the period specified and that supporting documents are available for audit.                                         DATE:____________________




                                                                                                                                                                                              08/05/08 V2.3
                                                                                          Schedule "D"
                                                                             Appendix 2 - Financial Quarterly Report
                                                                    [insert name of] Family Health Team, FHT Group #: XXX
                                                                                          For the Period
                                                                                          April 1, 2XXX
                                                                                                to
                                                                                       September 30, 2XXX


                                                                                              Actual                                                         Variance          Variance Explanation/
                                                                             Actual                              Forecast to End of
                                                       Approved                            Year-To-Date                               Total Forecast      (Overspending)/           Comments
                Budget Categories                                              Q2                                 Current Fiscal
                                                                                              (YTD)
                                                        Budget1            Expenditure                                                                    Underspending3
                                                                                           Expenditure                 Year2
                     Column 1                                                                                                         (Col. 4 + Col. 5)
                                                       Column 2             Column 3                                                     Column 6         (Col. 2 - Col. 6)
                                                                                               Column 4              Column 5
                                                                                                                                                            Column 7                Column 7
                   Human Resources
Management and Administrative Personnel
Executive Director                                                0.00                                    0.00                                     0.00                 0.00
Administrative Lead                                               0.00                                    0.00                                     0.00                 0.00
Administrative Lead (small FHT)                                   0.00                                    0.00                                     0.00                 0.00
Finance Manager                                                   0.00                                    0.00                                     0.00                 0.00
Office Administrator / Manager                                    0.00                                    0.00                                     0.00                 0.00
Program Administrator                                             0.00                                    0.00                                     0.00                 0.00
Administrative Assistant                                          0.00                                    0.00                                     0.00                 0.00
Receptionist / Clerical Staff                                     0.00                                    0.00                                     0.00                 0.00
Admin/Support for Blended Salary Model Physician                  0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
[Enter Other M or A Staff]                                        0.00                                    0.00                                     0.00                 0.00
Sub-total Management and Admin Salaries            $              -    $               -   $              -    $                -     $            -    $               -
Interdisciplinary Providers
Nurse Practitioner                                                0.00                                    0.00                                     0.00                 0.00
                                                                                                                                                                                08/05/08 V2.3
                                                                                           Actual                                                         Variance          Variance Explanation/
                                                                          Actual                              Forecast to End of
                                                    Approved                            Year-To-Date                               Total Forecast      (Overspending)/           Comments
                 Budget Categories                                          Q2                                 Current Fiscal
                                                                                           (YTD)
                                                     Budget1            Expenditure                                                                    Underspending3
                                                                                        Expenditure                 Year2
                     Column 1                                                                                                      (Col. 4 + Col. 5)
                                                    Column 2             Column 3                                                     Column 6         (Col. 2 - Col. 6)
                                                                                            Column 4              Column 5
                                                                                                                                                         Column 7                Column 7
                 Human Resources
Registered Nurse                                               0.00                                    0.00                                     0.00                 0.00
Registered Practical Nurse                                     0.00                                    0.00                                     0.00                 0.00
Registered Dietician                                           0.00                                    0.00                                     0.00                 0.00
Pharmacist                                                     0.00                                    0.00                                     0.00                 0.00
Social Worker                                                  0.00                                    0.00                                     0.00                 0.00
Social Worker (3 yrs. Exp + MSW)                               0.00                                    0.00                                     0.00                 0.00
Psychological Associate                                        0.00                                    0.00                                     0.00                 0.00
Psychologist                                                   0.00                                    0.00                                     0.00                 0.00
Health Educator/Promoter                                       0.00                                    0.00                                     0.00                 0.00
Mental Health Worker                                           0.00                                    0.00                                     0.00                 0.00
Chiropodist/Podiatrist                                         0.00                                    0.00                                     0.00                 0.00
Case Worker/Manager                                            0.00                                    0.00                                     0.00                 0.00
Speech Therapist                                               0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
[Enter Other Interdisciplinary Provider]                       0.00                                    0.00                                     0.00                 0.00
Sub-total Interdisciplinary Provider Salaries   $              -    $               -   $              -    $                -     $            -    $               -
Benefits @ 20%                                  $              -    $               -   $              -    $                -     $            -    $               -
Total Salaries & Benefits                       $              -    $               -   $              -    $                -     $            -    $               -
Salaried Physician Personnel:
BSM/Salaried Physician (Level 1)                               0.00                                    0.00                                     0.00                 0.00
BSM/Salaried Physician (Level 2)                               0.00                                    0.00                                     0.00                 0.00
BSM/Salaried Physician (Level 3)                               0.00                                    0.00                                     0.00                 0.00
IS-BSM New Grad/FP without Billing History                     0.00                                    0.00                                     0.00                 0.00
IS-BSM 12 Mo. FFS or non-FFS model                             0.00                                    0.00                                     0.00                 0.00
                                                                                                                                                                             08/05/08 V2.3
                                                                                                   Actual                                                         Variance          Variance Explanation/
                                                                                  Actual                              Forecast to End of
                                                            Approved                            Year-To-Date                               Total Forecast      (Overspending)/           Comments
                 Budget Categories                                                  Q2                                 Current Fiscal
                                                                                                   (YTD)
                                                             Budget1            Expenditure                                                                    Underspending3
                                                                                                Expenditure                 Year2
                     Column 1                                                                                                              (Col. 4 + Col. 5)
                                                            Column 2             Column 3                                                     Column 6         (Col. 2 - Col. 6)
                                                                                                    Column 4              Column 5
                                                                                                                                                                 Column 7                Column 7
                   Human Resources
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                    0.00                                     0.00                 0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                    0.00                                     0.00                 0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                    0.00                                     0.00                 0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                    0.00                                     0.00                 0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                    0.00                                     0.00                 0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                    0.00                                     0.00                 0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                    0.00                                     0.00                 0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                    0.00                                     0.00                 0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                    0.00                                     0.00                 0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                    0.00                                     0.00                 0.00
Sub-Total Physician Salaries                            $              -    $               -   $              -      $              -     $            -      $             -
Sub-Total Physician Locum Allowance                     $              -                        $              -      $              -     $            -      $             -
THAS                                                    $              -                        $              -      $              -     $            -      $             -
Benefits @ 20%                                          $              -                        $              -      $              -     $            -      $             -
Total BSM/Salaried Physician Salaries                   $              -    $               -   $              -      $              -     $            -      $             -
Specialists:
Psychiatrist Sessions                                                  0.00                                    0.00                                     0.00                 0.00
Geriatrician sessions                                                  0.00                                    0.00                                     0.00                 0.00
Paediatrician Sessions                                                 0.00                                    0.00                                     0.00                 0.00
Internist Sessions                                                     0.00                                    0.00                                     0.00                 0.00
[Enter Other Specialist]                                               0.00                                    0.00                                     0.00                 0.00
[Enter Other Specialist]                                               0.00                                    0.00                                     0.00                 0.00
[Enter Other Specialist]                                               0.00                                    0.00                                     0.00                 0.00
[Enter Other Specialist]                                               0.00                                    0.00                                     0.00                 0.00
[Enter Other Specialist]                                               0.00                                    0.00                                     0.00                 0.00
[Enter Other Specialist]                                               0.00                                    0.00                                     0.00                 0.00
[Enter Other Specialist]                                               0.00                                    0.00                                     0.00                 0.00
[Enter Other Specialist]                                               0.00                                    0.00                                     0.00                 0.00
[Enter Other Specialist]                                               0.00                                    0.00                                     0.00                 0.00
[Enter Other Specialist]                                               0.00                                    0.00                                     0.00                 0.00
Total Specialist Compensation                           $              -    $               -   $              -    $                -     $            -    $               -
Total Human Resources                                   $              -    $               -   $              -    $                -     $            -    $               -
                    Other Overhead
Equipment Lease and Service Contracts:
                                   Photocopier Lease                   0.00                                    0.00                                     0.00                 0.00
                           Equipment Leases (specify)                  0.00                                    0.00                                     0.00                 0.00
                           Equipment Leases (specify)                  0.00                                    0.00                                     0.00                 0.00
                           Equipment Leases (specify)                  0.00                                    0.00                                     0.00                 0.00
                           Equipment Leases (specify)                  0.00                                    0.00                                     0.00                 0.00
                           Equipment Leases (specify)                  0.00                                    0.00                                     0.00                 0.00
                           Equipment Leases (specify)                  0.00                                    0.00                                     0.00                 0.00
                           Equipment Leases (specify)                  0.00                                    0.00                                     0.00                 0.00
                                                                                                                                                                                     08/05/08 V2.3
                                                                                                   Actual                                                       Variance          Variance Explanation/
                                                                               Actual                              Forecast to End of
                                                           Approved                             Year-To-Date                             Total Forecast      (Overspending)/           Comments
                  Budget Categories                                              Q2                                 Current Fiscal
                                                                                                   (YTD)
                                                            Budget1          Expenditure                                                                     Underspending3
                                                                                                Expenditure              Year2
                      Column 1                                                                                                           (Col. 4 + Col. 5)
                                                           Column 2           Column 3                                                      Column 6         (Col. 2 - Col. 6)
                                                                                                 Column 4              Column 5
                                                                                                                                                               Column 7                Column 7
                  Human Resources
                             Equipment Leases (specify)               0.00                                  0.00                                      0.00                 0.00
                             Equipment Leases (specify)               0.00                                  0.00                                      0.00                 0.00
                             Equipment Leases (specify)               0.00                                  0.00                                      0.00                 0.00
                  Equipment Service Contract (specify)                0.00                                  0.00                                      0.00                 0.00
                  Equipment Service Contract (specify)                0.00                                  0.00                                      0.00                 0.00
                  Equipment Service Contract (specify)                0.00                                  0.00                                      0.00                 0.00
                  Equipment Service Contract (specify)                0.00                                  0.00                                      0.00                 0.00
                  Equipment Service Contract (specify)                0.00                                  0.00                                      0.00                 0.00
                  Equipment Service Contract (specify)                0.00                                  0.00                                      0.00                 0.00
                  Equipment Service Contract (specify)                0.00                                  0.00                                      0.00                 0.00
                  Equipment Service Contract (specify)                0.00                                  0.00                                      0.00                 0.00
                  Equipment Service Contract (specify)                0.00                                  0.00                                      0.00                 0.00
                  Equipment Service Contract (specify)                0.00                                  0.00                                      0.00                 0.00
Sub-Total Equipment Lease and Service Contracts                       0.00               0.00               0.00                  0.00                0.00                 0.00
General Overhead4
                                             Advertising              0.00                                  0.00                                      0.00                 0.00
                                       Medical Supplies               0.00                                  0.00                                      0.00                 0.00
                              Communication Materials                 0.00                                  0.00                                      0.00                 0.00
 Cell Phone/Wireless Handheld/Telephone Line/Service                  0.00                                  0.00                                      0.00                 0.00
                     FHT Association Membership Fees                  0.00                                  0.00                                      0.00                 0.00
           Stationary/Printing/Copying/Postage/Courier                0.00                                  0.00                                      0.00                 0.00
                                         Office Supplies              0.00                                  0.00                                      0.00                 0.00
                                         Medical Waste                0.00                                  0.00                                      0.00                 0.00
                                       Library Materials              0.00                                  0.00                                      0.00                 0.00
                                Payroll Service Contract              0.00                                  0.00                                      0.00                 0.00
                                             Translation              0.00                                  0.00                                      0.00                 0.00
                                 Other (please describe)              0.00                                  0.00                                      0.00                 0.00
                                 Other (please describe)              0.00                                  0.00                                      0.00                 0.00
                                 Other (please describe)              0.00                                  0.00                                      0.00                 0.00
                                 Other (please describe)              0.00                                  0.00                                      0.00                 0.00
                                 Other (please describe)              0.00                                  0.00                                      0.00                 0.00
                                 Other (please describe)              0.00                                  0.00                                      0.00                 0.00
                                 Other (please describe)              0.00                                  0.00                                      0.00                 0.00
                                 Other (please describe)              0.00                                  0.00                                      0.00                 0.00
                                 Other (please describe)              0.00                                  0.00                                      0.00                 0.00
                                 Other (please describe)              0.00                                  0.00                                      0.00                 0.00
Sub-Total General Overhead                                            0.00               0.00               0.00                  0.00                0.00                 0.00
Information Technology Other Operational Overhead
                         IT Hardware (Annual Ongoing)                 0.00                                  0.00                                      0.00                 0.00
                          IT Software (Annual Ongoing)                0.00                                  0.00                                      0.00                 0.00
      Other IT Costs - Please Specify (Annual/Ongoing)                0.00                                  0.00                                      0.00                 0.00
      Other IT Costs - Please Specify (Annual/Ongoing)                0.00                                  0.00                                      0.00                 0.00
                                                                                                                                                                                   08/05/08 V2.3
                                                                                                Actual                                                       Variance          Variance Explanation/
                                                                            Actual                              Forecast to End of
                                                        Approved                             Year-To-Date                             Total Forecast      (Overspending)/           Comments
                 Budget Categories                                            Q2                                 Current Fiscal
                                                                                                (YTD)
                                                         Budget1          Expenditure                                                                     Underspending3
                                                                                             Expenditure              Year2
                     Column 1                                                                                                         (Col. 4 + Col. 5)
                                                        Column 2           Column 3                                                      Column 6         (Col. 2 - Col. 6)
                                                                                              Column 4              Column 5
                                                                                                                                                            Column 7                Column 7
                 Human Resources
     Other IT Costs - Please Specify (Annual/Ongoing)              0.00                                  0.00                                      0.00                 0.00
     Other IT Costs - Please Specify (Annual/Ongoing)              0.00                                  0.00                                      0.00                 0.00
     Other IT Costs - Please Specify (Annual/Ongoing)              0.00                                  0.00                                      0.00                 0.00
     Other IT Costs - Please Specify (Annual/Ongoing)              0.00                                  0.00                                      0.00                 0.00
     Other IT Costs - Please Specify (Annual/Ongoing)              0.00                                  0.00                                      0.00                 0.00
     Other IT Costs - Please Specify (Annual/Ongoing)              0.00                                  0.00                                      0.00                 0.00
     Other IT Costs - Please Specify (Annual/Ongoing)              0.00                                  0.00                                      0.00                 0.00
     Other IT Costs - Please Specify (Annual/Ongoing)              0.00                                  0.00                                      0.00                 0.00
Sub-Total IT Ongoing Overhead                                      0.00               0.00               0.00                  0.00                0.00                 0.00
Travel                                                             0.00                                  0.00                                      0.00                 0.00
Professional Development                                           0.00                                  0.00                                      0.00                 0.00
Audit                                                              0.00                                  0.00                                      0.00                 0.00
Legal                                                              0.00                                  0.00                                      0.00                 0.00
General Consulting                                                 0.00                                  0.00                                      0.00                 0.00
Recruitment                                                        0.00                                  0.00                                      0.00                 0.00
Physician Consulting                                               0.00                                  0.00                                      0.00                 0.00
Rent                                                               0.00                                  0.00                                      0.00                 0.00
Property tax and Utilities                                         0.00                                  0.00                                      0.00                 0.00
Common Area Maintenance                                            0.00                                  0.00                                      0.00                 0.00
Security System                                                    0.00                                  0.00                                      0.00                 0.00
Insurance                                                          0.00                                  0.00                                      0.00                 0.00
Program Development Consulting                                     0.00                                  0.00                                      0.00                 0.00
Other Overhead (please describe)                                   0.00                                  0.00                                      0.00                 0.00
Other Overhead (please describe)                                   0.00                                  0.00                                      0.00                 0.00
Other Overhead (please describe)                                   0.00                                  0.00                                      0.00                 0.00
Other Overhead (please describe)                                   0.00                                  0.00                                      0.00                 0.00
Other Overhead (please describe)                                   0.00                                  0.00                                      0.00                 0.00
Other Overhead (please describe)                                   0.00                                  0.00                                      0.00                 0.00
Other Overhead (please describe)                                   0.00                                  0.00                                      0.00                 0.00
Other Overhead (please describe)                                   0.00                                  0.00                                      0.00                 0.00
Other Overhead (please describe)                                   0.00                                  0.00                                      0.00                 0.00
Other Overhead (please describe)                                   0.00                                  0.00                                      0.00                 0.00
Total Other Overhead Costs                                         0.00               0.00               0.00                  0.00                0.00                 0.00
                  One-Time Costs
Office Furnishings                                                 0.00                                  0.00                                      0.00                 0.00
Clinical Equipment                                                 0.00                                  0.00                                      0.00                 0.00
One-Time IT Hardware                                               0.00                                  0.00                                      0.00                 0.00
One-Time IT Software                                               0.00                                  0.00                                      0.00                 0.00
Signage                                                            0.00                                  0.00                                      0.00                 0.00
One-Time Telecommunications                                        0.00                                  0.00                                      0.00                 0.00
Moving Costs                                                       0.00                                  0.00                                      0.00                 0.00
Other One-Time (please describe)                                   0.00                                  0.00                                      0.00                 0.00
                                                                                                                                                                                08/05/08 V2.3
                                                                                                               Actual                                                        Variance              Variance Explanation/
                                                                                      Actual                                 Forecast to End of
                                                                Approved                                    Year-To-Date                                 Total Forecast   (Overspending)/               Comments
                   Budget Categories                                                    Q2                                    Current Fiscal
                                                                                                               (YTD)
                                                                 Budget1            Expenditure                                                                           Underspending3
                                                                                                            Expenditure            Year2
                       Column 1                                                                                                                      (Col. 4 + Col. 5)
                                                                Column 2             Column 3                                                           Column 6          (Col. 2 - Col. 6)
                                                                                                             Column 4            Column 5
                                                                                                                                                                            Column 7                    Column 7
                Human Resources
Other One-Time (please describe)                                           0.00                                         0.00                                        0.00                0.00
Other One-Time (please describe)                                           0.00                                         0.00                                        0.00                0.00
Other One-Time (please describe)                                           0.00                                         0.00                                        0.00                0.00
Other One-Time (please describe)                                           0.00                                         0.00                                        0.00                0.00
Other One-Time (please describe)                                           0.00                                         0.00                                        0.00                0.00
Other One-Time (please describe)                                           0.00                                         0.00                                        0.00                0.00
Other One-Time (please describe)                                           0.00                                         0.00                                        0.00                0.00
Other One-Time (please describe)                                           0.00                                         0.00                                        0.00                0.00
Other One-Time (please describe)                                           0.00                                         0.00                                        0.00                0.00
Total Start Up/One-Time Costs                               $              -    $               -       $               -    $               -       $              -    $              -

Totals                                                  $              -   $                        -   $                -   $                   -   $               -    $                 -
Interest Rate in Interest-bearing account (e.g.; 3.00%)
Interest accrued from [Date of funds deposited] to [insert end of funding period]                                                                                         $             -
Amount recoverable by the Ministry                                                                                                                                        $             -

1 As defined in Schedule B of the Interim Funding Agreement
2 Estimate of total expenditures incurred from end of this reporting period to the end of the current fiscal year (e.g. March 31, 2008)
3 Approved Budget Allocation minus the Total Forecast.
4 General Overhead expenditures must be reported on in detail as per the sub-categories (e.g. medical supplies, payroll service contract).

I certify that this is an accurate account of expenditures for the period specified and that supporting documents are available for audit.                                                      DATE:____________________




                                                                                                                                                                                                    08/05/08 V2.3
08/05/08 V2.3
08/05/08 V2.3
08/05/08 V2.3
08/05/08 V2.3
08/05/08 V2.3
DATE:____________________




                            08/05/08 V2.3
                                                                                    Schedule "D"
                                                                       Appendix 2 - Financial Quarterly Report
                                                              [insert name of] Family Health Team, FHT Group #: XXX
                                                                                    For the Period
                                                                                    April 1, 2XXX
                                                                                          to
                                                                                 December 31, 2XXX


                                                                                              Actual                                                 Variance         Variance Explanation/
                                                                             Actual                        Forecast to End
                                                       Approved                            Year-To-Date                       Total Forecast      (Overspending)/          Comments
                Budget Categories                                              Q3                         of Current Fiscal
                                                                                              (YTD)
                                                        Budget1            Expenditure                                                            Underspending3
                                                                                           Expenditure         Year2
                    Column 1                                                                                                  (Col. 4 + Col. 5)
                                                       Column 2             Column 3                                             Column 6         (Col. 2 - Col. 6)
                                                                                               Column 4        Column 5
                                                                                                                                                    Column 7               Column 7
                  Human Resources
Management and Administrative Personnel
Executive Director                                                0.00                                0.00                                 0.00                0.00
Administrative Lead                                               0.00                                0.00                                 0.00                0.00
Administrative Lead (small FHT)                                   0.00                                0.00                                 0.00                0.00
Finance Manager                                                   0.00                                0.00                                 0.00                0.00
Office Administrator / Manager                                    0.00                                0.00                                 0.00                0.00
Program Administrator                                             0.00                                0.00                                 0.00                0.00
Administrative Assistant                                          0.00                                0.00                                 0.00                0.00
Receptionist / Clerical Staff                                     0.00                                0.00                                 0.00                0.00
Admin/Support for Blended Salary Model Physician                  0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
[Enter Other M or A Staff]                                        0.00                                0.00                                 0.00                0.00
Sub-total Management and Admin Salaries            $              -    $               -   $          -    $              -   $            -    $              -
                                                                                                                                                                      08/05/08 V2.3
                                                                                           Actual                                                    Variance         Variance Explanation/
                                                                          Actual                           Forecast to End
                                                    Approved                            Year-To-Date                          Total Forecast      (Overspending)/          Comments
                 Budget Categories                                          Q3                            of Current Fiscal
                                                            1                              (YTD)                                                                3
                                                     Budget             Expenditure                                  2                            Underspending
                                                                                        Expenditure            Year
                     Column 1                                                                                                 (Col. 4 + Col. 5)
                                                    Column 2             Column 3                                                Column 6         (Col. 2 - Col. 6)
                                                                                            Column 4         Column 5
                                                                                                                                                    Column 7               Column 7
                  Human Resources
Interdisciplinary Providers
Nurse Practitioner                                             0.00                                0.00                                    0.00                0.00
Registered Nurse                                               0.00                                0.00                                    0.00                0.00
Registered Practical Nurse                                     0.00                                0.00                                    0.00                0.00
Registered Dietician                                           0.00                                0.00                                    0.00                0.00
Pharmacist                                                     0.00                                0.00                                    0.00                0.00
Social Worker                                                  0.00                                0.00                                    0.00                0.00
Social Worker (3 yrs. Exp + MSW)                               0.00                                0.00                                    0.00                0.00
Psychological Associate                                        0.00                                0.00                                    0.00                0.00
Psychologist                                                   0.00                                0.00                                    0.00                0.00
Health Educator/Promoter                                       0.00                                0.00                                    0.00                0.00
Mental Health Worker                                           0.00                                0.00                                    0.00                0.00
Chiropodist/Podiatrist                                         0.00                                0.00                                    0.00                0.00
Case Worker/Manager                                            0.00                                0.00                                    0.00                0.00
Speech Therapist                                               0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
[Enter Other Interdisciplinary Provider]                       0.00                                0.00                                    0.00                0.00
Sub-total Interdisciplinary Provider Salaries   $              -    $               -   $          -    $               -     $            -    $              -
Benefits @ 20%                                  $              -                        $          -    $               -     $            -    $              -
Total Salaries & Benefits                       $              -    $               -   $          -    $               -     $            -    $              -
Salaried Physician Personnel:
BSM/Salaried Physician (Level 1)                               0.00                                0.00                                    0.00                0.00
                                                                                                                                                                      08/05/08 V2.3
                                                                                                   Actual                                                    Variance         Variance Explanation/
                                                                                  Actual                           Forecast to End
                                                            Approved                            Year-To-Date                          Total Forecast      (Overspending)/          Comments
                 Budget Categories                                                  Q3                            of Current Fiscal
                                                                    1                              (YTD)                                                                3
                                                             Budget             Expenditure                                  2                            Underspending
                                                                                                Expenditure            Year
                     Column 1                                                                                                         (Col. 4 + Col. 5)
                                                            Column 2             Column 3                                                Column 6         (Col. 2 - Col. 6)
                                                                                                    Column 4          Column 5
                                                                                                                                                            Column 7               Column 7
                   Human Resources
BSM/Salaried Physician (Level 2)                                       0.00                                0.00                                    0.00                0.00
BSM/Salaried Physician (Level 3)                                       0.00                                0.00                                    0.00                0.00
IS-BSM New Grad/FP without Billing History                             0.00                                0.00                                    0.00                0.00
IS-BSM 12 Mo. FFS or non-FFS model                                     0.00                                0.00                                    0.00                0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                0.00                                    0.00                0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                0.00                                    0.00                0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                0.00                                    0.00                0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                0.00                                    0.00                0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                0.00                                    0.00                0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                0.00                                    0.00                0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                0.00                                    0.00                0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                0.00                                    0.00                0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                0.00                                    0.00                0.00
[Enter Other BSM/IS-BSM Physicians]                                    0.00                                0.00                                    0.00                0.00
Sub-Total Physician Salaries                            $              -    $               -   $          -      $              -    $            -      $            -
Sub-Total Physician Locum Allowance                     $              -                        $          -      $              -    $            -      $            -
THAS                                                    $              -                        $          -      $              -    $            -      $            -
Benefits @ 20%                                          $              -                        $          -      $              -    $            -      $            -
Total BSM/Salaried Physician Salaries                   $              -    $               -   $          -      $              -    $            -      $            -
Specialists:
Psychiatrist Sessions                                                  0.00                                0.00                                    0.00                0.00
Geriatrician sessions                                                  0.00                                0.00                                    0.00                0.00
Paediatrician Sessions                                                 0.00                                0.00                                    0.00                0.00
Internist Sessions                                                     0.00                                0.00                                    0.00                0.00
[Enter Other Specialist]                                               0.00                                0.00                                    0.00                0.00
[Enter Other Specialist]                                               0.00                                0.00                                    0.00                0.00
[Enter Other Specialist]                                               0.00                                0.00                                    0.00                0.00
[Enter Other Specialist]                                               0.00                                0.00                                    0.00                0.00
[Enter Other Specialist]                                               0.00                                0.00                                    0.00                0.00
[Enter Other Specialist]                                               0.00                                0.00                                    0.00                0.00
[Enter Other Specialist]                                               0.00                                0.00                                    0.00                0.00
[Enter Other Specialist]                                               0.00                                0.00                                    0.00                0.00
[Enter Other Specialist]                                               0.00                                0.00                                    0.00                0.00
[Enter Other Specialist]                                               0.00                                0.00                                    0.00                0.00
Total Specialist Compensation                           $              -    $               -   $          -    $                -    $            -    $              -
Total Human Resources                                   $              -    $               -   $          -    $                -    $            -    $              -
                    Other Overhead
Equipment Lease and Service Contracts:
                                   Photocopier Lease                   0.00                                0.00                                    0.00                0.00
                           Equipment Leases (specify)                  0.00                                0.00                                    0.00                0.00
                                                                                                                                                                              08/05/08 V2.3
                                                                                                 Actual                                                   Variance         Variance Explanation/
                                                                             Actual                            Forecast to End
                                                         Approved                             Year-To-Date                         Total Forecast      (Overspending)/          Comments
                 Budget Categories                                             Q3                             of Current Fiscal
                                                                 1                               (YTD)                                                               3
                                                          Budget           Expenditure                                   2                             Underspending
                                                                                              Expenditure          Year
                      Column 1                                                                                                     (Col. 4 + Col. 5)
                                                         Column 2           Column 3                                                  Column 6         (Col. 2 - Col. 6)
                                                                                               Column 4          Column 5
                                                                                                                                                         Column 7               Column 7
                 Human Resources
                           Equipment Leases (specify)               0.00                               0.00                                     0.00                0.00
                           Equipment Leases (specify)               0.00                               0.00                                     0.00                0.00
                           Equipment Leases (specify)               0.00                               0.00                                     0.00                0.00
                           Equipment Leases (specify)               0.00                               0.00                                     0.00                0.00
                           Equipment Leases (specify)               0.00                               0.00                                     0.00                0.00
                           Equipment Leases (specify)               0.00                               0.00                                     0.00                0.00
                           Equipment Leases (specify)               0.00                               0.00                                     0.00                0.00
                           Equipment Leases (specify)               0.00                               0.00                                     0.00                0.00
                           Equipment Leases (specify)               0.00                               0.00                                     0.00                0.00
                 Equipment Service Contract (specify)               0.00                               0.00                                     0.00                0.00
                 Equipment Service Contract (specify)               0.00                               0.00                                     0.00                0.00
                 Equipment Service Contract (specify)               0.00                               0.00                                     0.00                0.00
                 Equipment Service Contract (specify)               0.00                               0.00                                     0.00                0.00
                 Equipment Service Contract (specify)               0.00                               0.00                                     0.00                0.00
                 Equipment Service Contract (specify)               0.00                               0.00                                     0.00                0.00
                 Equipment Service Contract (specify)               0.00                               0.00                                     0.00                0.00
                 Equipment Service Contract (specify)               0.00                               0.00                                     0.00                0.00
                 Equipment Service Contract (specify)               0.00                               0.00                                     0.00                0.00
                 Equipment Service Contract (specify)               0.00                               0.00                                     0.00                0.00
Sub-Total Equipment Lease and Service Contracts                     0.00               0.00            0.00                 0.00                0.00                0.00
General Overhead4
                                           Advertising              0.00                               0.00                                     0.00                0.00
                                     Medical Supplies               0.00                               0.00                                     0.00                0.00
                            Communication Materials                 0.00                               0.00                                     0.00                0.00
Cell Phone/Wireless Handheld/Telephone Line/Service                 0.00                               0.00                                     0.00                0.00
                   FHT Association Membership Fees                  0.00                               0.00                                     0.00                0.00
          Stationary/Printing/Copying/Postage/Courier               0.00                               0.00                                     0.00                0.00
                                       Office Supplies              0.00                               0.00                                     0.00                0.00
                                       Medical Waste                0.00                               0.00                                     0.00                0.00
                                     Library Materials              0.00                               0.00                                     0.00                0.00
                              Payroll Service Contract              0.00                               0.00                                     0.00                0.00
                                           Translation              0.00                               0.00                                     0.00                0.00
                               Other (please describe)              0.00                               0.00                                     0.00                0.00
                               Other (please describe)              0.00                               0.00                                     0.00                0.00
                               Other (please describe)              0.00                               0.00                                     0.00                0.00
                               Other (please describe)              0.00                               0.00                                     0.00                0.00
                               Other (please describe)              0.00                               0.00                                     0.00                0.00
                               Other (please describe)              0.00                               0.00                                     0.00                0.00
                               Other (please describe)              0.00                               0.00                                     0.00                0.00
                               Other (please describe)              0.00                               0.00                                     0.00                0.00
                                                                                                                                                                           08/05/08 V2.3
                                                                                                  Actual                                                   Variance         Variance Explanation/
                                                                              Actual                            Forecast to End
                                                          Approved                             Year-To-Date                         Total Forecast      (Overspending)/          Comments
                 Budget Categories                                              Q3                             of Current Fiscal
                                                                  1                               (YTD)                                                               3
                                                           Budget           Expenditure                                   2                             Underspending
                                                                                               Expenditure          Year
                     Column 1                                                                                                       (Col. 4 + Col. 5)
                                                          Column 2           Column 3                                                  Column 6         (Col. 2 - Col. 6)
                                                                                                Column 4          Column 5
                                                                                                                                                          Column 7               Column 7
                 Human Resources
                                Other (please describe)              0.00                               0.00                                     0.00                0.00
                                Other (please describe)              0.00                               0.00                                     0.00                0.00
Sub-Total General Overhead                                           0.00               0.00            0.00                 0.00                0.00                0.00
Information Technology Other Operational Overhead
                        IT Hardware (Annual Ongoing)                 0.00                               0.00                                     0.00                0.00
                         IT Software (Annual Ongoing)                0.00                               0.00                                     0.00                0.00
     Other IT Costs - Please Specify (Annual/Ongoing)                0.00                               0.00                                     0.00                0.00
     Other IT Costs - Please Specify (Annual/Ongoing)                0.00                               0.00                                     0.00                0.00
     Other IT Costs - Please Specify (Annual/Ongoing)                0.00                               0.00                                     0.00                0.00
     Other IT Costs - Please Specify (Annual/Ongoing)                0.00                               0.00                                     0.00                0.00
     Other IT Costs - Please Specify (Annual/Ongoing)                0.00                               0.00                                     0.00                0.00
     Other IT Costs - Please Specify (Annual/Ongoing)                0.00                               0.00                                     0.00                0.00
     Other IT Costs - Please Specify (Annual/Ongoing)                0.00                               0.00                                     0.00                0.00
     Other IT Costs - Please Specify (Annual/Ongoing)                0.00                               0.00                                     0.00                0.00
     Other IT Costs - Please Specify (Annual/Ongoing)                0.00                               0.00                                     0.00                0.00
     Other IT Costs - Please Specify (Annual/Ongoing)                0.00                               0.00                                     0.00                0.00
Sub-Total IT Ongoing Overhead                                        0.00               0.00            0.00                 0.00                0.00                0.00
Travel                                                               0.00                               0.00                                     0.00                0.00
Professional Development                                             0.00                               0.00                                     0.00                0.00
Audit                                                                0.00                               0.00                                     0.00                0.00
Legal                                                                0.00                               0.00                                     0.00                0.00
General Consulting                                                   0.00                               0.00                                     0.00                0.00
Recruitment                                                          0.00                               0.00                                     0.00                0.00
Physician Consulting                                                 0.00                               0.00                                     0.00                0.00
Rent                                                                 0.00                               0.00                                     0.00                0.00
Property tax and Utilities                                           0.00                               0.00                                     0.00                0.00
Common Area Maintenance                                              0.00                               0.00                                     0.00                0.00
Security System                                                      0.00                               0.00                                     0.00                0.00
Insurance                                                            0.00                               0.00                                     0.00                0.00
Program Development Consulting                                       0.00                               0.00                                     0.00                0.00
Other Overhead (please describe)                                     0.00                               0.00                                     0.00                0.00
Other Overhead (please describe)                                     0.00                               0.00                                     0.00                0.00
Other Overhead (please describe)                                     0.00                               0.00                                     0.00                0.00
Other Overhead (please describe)                                     0.00                               0.00                                     0.00                0.00
Other Overhead (please describe)                                     0.00                               0.00                                     0.00                0.00
Other Overhead (please describe)                                     0.00                               0.00                                     0.00                0.00
Other Overhead (please describe)                                     0.00                               0.00                                     0.00                0.00
Other Overhead (please describe)                                     0.00                               0.00                                     0.00                0.00
Other Overhead (please describe)                                     0.00                               0.00                                     0.00                0.00
                                                                                                                                                                            08/05/08 V2.3
                                                                                                         Actual                                                         Variance          Variance Explanation/
                                                                                     Actual                               Forecast to End
                                                               Approved                               Year-To-Date                                 Total Forecast    (Overspending)/           Comments
                  Budget Categories                                                    Q3                                of Current Fiscal
                                                                       1                                 (YTD)                                                                     3
                                                                Budget             Expenditure                                      2                                Underspending
                                                                                                      Expenditure             Year
                       Column 1                                                                                                                (Col. 4 + Col. 5)
                                                               Column 2             Column 3                                                      Column 6           (Col. 2 - Col. 6)
                                                                                                          Column 4           Column 5
                                                                                                                                                                       Column 7                Column 7
                 Human Resources
Other Overhead (please describe)                                          0.00                                    0.00                                        0.00                0.00
Total Other Overhead Costs                                                0.00                 0.00               0.00                  0.00                  0.00                0.00
                  One-Time Costs
Office Furnishings                                                        0.00                                    0.00                                        0.00                0.00
Clinical Equipment                                                        0.00                                    0.00                                        0.00                0.00
One-Time IT Hardware                                                      0.00                                    0.00                                        0.00                0.00
One-Time IT Software                                                      0.00                                    0.00                                        0.00                0.00
Signage                                                                   0.00                                    0.00                                        0.00                0.00
One-Time Telecommunications                                               0.00                                    0.00                                        0.00                0.00
Moving Costs                                                              0.00                                    0.00                                        0.00                0.00
Other One-Time (please describe)                                          0.00                                    0.00                                        0.00                0.00
Other One-Time (please describe)                                          0.00                                    0.00                                        0.00                0.00
Other One-Time (please describe)                                          0.00                                    0.00                                        0.00                0.00
Other One-Time (please describe)                                          0.00                                    0.00                                        0.00                0.00
Other One-Time (please describe)                                          0.00                                    0.00                                        0.00                0.00
Other One-Time (please describe)                                          0.00                                    0.00                                        0.00                0.00
Other One-Time (please describe)                                          0.00                                    0.00                                        0.00                0.00
Other One-Time (please describe)                                          0.00                                    0.00                                        0.00                0.00
Other One-Time (please describe)                                          0.00                                    0.00                                        0.00                0.00
Other One-Time (please describe)                                          0.00                                    0.00                                        0.00                0.00
Total Start Up/One-Time Costs                              $              -    $               -      $           -    $                -      $              -    $              -

Totals                                                 $             -    $                    -      $              -   $              -      $               -     $             -
Interest Rate in Interest-bearing account (e.g.; 3.00%)
Interest accrued from [Date of funds deposited] to [insert end of funding period]                                                                                    $            -
Amount recoverable by the Ministry                                                                                                                                   $            -

1 As defined in Schedule B of the Interim Funding Agreement
2 Estimate of total expenditures incurred from end of this reporting period to the end of the current fiscal year (e.g. March 31, 2008)
3 Approved Budget Allocation minus the Total Forecast.
4 General Overhead expenditures must be reported on in detail as per the sub-categories (e.g. medical supplies, payroll service contract).

I certify that this is an accurate account of expenditures for the period specified and that supporting documents are available for audit.                                               DATE:____________________




                                                                                                                                                                                          08/05/08 V2.3
08/05/08 V2.3
08/05/08 V2.3
08/05/08 V2.3
08/05/08 V2.3
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DATE:____________________




                            08/05/08 V2.3
                                                                         Schedule "D"
                                                     Appendix 3 - Statement of Revenues and Expenditures
                                                   [insert name of] Family Health Team, FHT Group #: XXX
                                                                         For the Period
                                                                         April 1, 2XXX
                                                                               to
                                                                       March 31, 2XXX

                                                                      EXPENDITURES
                                                                                                  Actual            Variance
                                                                             Actual                                                       Variance Explanation/
                                                       Approved                                   Annual         (Overspending)/
                 Budget Categories                                             Q4                          2                                   Comments
                                                        Budget1                                Expenditures      Underspending3
                                                                           Expenditure
                      Column 1
                                                       Column 2             Column 3                                 (Col. 2 - Col. 4)
                                                                                                 Column 4                                      Column 6
                                                                                                                       Column 5
                    Human Resources
Management and Administrative Personnel
Executive Director                                                0.00                                      0.00                   0.00
Administrative Lead                                               0.00                                      0.00                   0.00
Administrative Lead (small FHT)                                   0.00                                      0.00                   0.00
Finance Manager                                                   0.00                                      0.00                   0.00
Office Administrator / Manager                                    0.00                                      0.00                   0.00
Program Administrator                                             0.00                                      0.00                   0.00
Administrative Assistant                                          0.00                                      0.00                   0.00
Receptionist / Clerical Staff                                     0.00                                      0.00                   0.00
Admin/Support for Blended Salary Model Physician                  0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
[Enter Other M or A Staff]                                        0.00                                      0.00                   0.00
Sub-total Management and Admin Salaries            $              -    $               -   $                -    $                 -
                                                                                                                                                      08/05/08 V2.3
                                                                       EXPENDITURES
                                                                                                Actual              Variance
                                                                           Actual                                                       Variance Explanation/
                                                    Approved                                    Annual           (Overspending)/
                  Budget Categories                                          Q4                          2                                   Comments
                                                     Budget
                                                            1                                Expenditures        Underspending
                                                                                                                               3
                                                                         Expenditure
                      Column 1
                                                    Column 2              Column 3                                 (Col. 2 - Col. 4)
                                                                                               Column 4                                      Column 6
                                                                                                                     Column 5
Interdisciplinary Providers
Nurse Practitioner                                              0.00                                      0.00                   0.00
Registered Nurse                                                0.00                                      0.00                   0.00
Registered Practical Nurse                                      0.00                                      0.00                   0.00
Registered Dietician                                            0.00                                      0.00                   0.00
Pharmacist                                                      0.00                                      0.00                   0.00
Social Worker                                                   0.00                                      0.00                   0.00
Social Worker (3 yrs. Exp + MSW)                                0.00                                      0.00                   0.00
Psychological Associate                                         0.00                                      0.00                   0.00
Psychologist                                                    0.00                                      0.00                   0.00
Health Educator/Promoter                                        0.00                                      0.00                   0.00
Mental Health Worker                                            0.00                                      0.00                   0.00
Chiropodist/Podiatrist                                          0.00                                      0.00                   0.00
Case Worker/Manager                                             0.00                                      0.00                   0.00
Speech Therapist                                                0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
[Enter Other Interdisciplinary Provider]                        0.00                                      0.00                   0.00
Sub-total Interdisciplinary Provider Salaries   $               -    $               -   $                -    $                 -
Benefits @ 20%                                  $               -                        $                -                      0.00
Total Salaries & Benefits                       $               -    $               -   $                -    $                 -
Salaried Physician Personnel:
BSM/Salaried Physician (Level 1)                                0.00                                      0.00                   0.00
BSM/Salaried Physician (Level 2)                                0.00                                      0.00                   0.00
                                                                                                                                                    08/05/08 V2.3
                                                                                 EXPENDITURES
                                                                                                          Actual              Variance
                                                                                     Actual                                                        Variance Explanation/
                                                              Approved                                    Annual           (Overspending)/
                  Budget Categories                                                    Q4                          2                                    Comments
                                                               Budget
                                                                      1                                Expenditures        Underspending
                                                                                                                                         3
                                                                                   Expenditure
                      Column 1
                                                              Column 2              Column 3                                 (Col. 2 - Col. 4)
                                                                                                         Column 4                                       Column 6
                                                                                                                               Column 5
BSM/Salaried Physician (Level 3)                                          0.00                                      0.00                    0.00
IS-BSM New Grad/FP without Billing History                                0.00                                      0.00                    0.00
IS-BSM 12 Mo. FFS or non-FFS model                                        0.00                                      0.00                    0.00
[Enter Other BSM/IS-BSM Physicians]                                       0.00                                      0.00                    0.00
[Enter Other BSM/IS-BSM Physicians]                                       0.00                                      0.00                    0.00
[Enter Other BSM/IS-BSM Physicians]                                       0.00                                      0.00                    0.00
[Enter Other BSM/IS-BSM Physicians]                                       0.00                                      0.00                    0.00
[Enter Other BSM/IS-BSM Physicians]                                       0.00                                      0.00                    0.00
[Enter Other BSM/IS-BSM Physicians]                                       0.00                                      0.00                    0.00
[Enter Other BSM/IS-BSM Physicians]                                       0.00                                      0.00                    0.00
[Enter Other BSM/IS-BSM Physicians]                                       0.00                                      0.00                    0.00
[Enter Other BSM/IS-BSM Physicians]                                       0.00                                      0.00                    0.00
[Enter Other BSM/IS-BSM Physicians]                                       0.00                                      0.00                    0.00
Sub-Total Physician Salaries                              $               -    $               -   $                -      $                -
Sub-Total Physician Locum Allowance                       $               -                        $                -                       0.00
THAS                                                      $               -                        $                -                       0.00
Benefits @ 20%                                            $               -                        $                -                       0.00
Total BSM/Salaried Physician Salaries                     $               -    $               -   $                -      $                -
Specialists:
Psychiatrist Sessions                                                     0.00                                      0.00                   0.00
Geriatrician sessions                                                     0.00                                      0.00                   0.00
Paediatrician Sessions                                                    0.00                                      0.00                   0.00
Internist Sessions                                                        0.00                                      0.00                   0.00
[Enter Other Specialist]                                                  0.00                                      0.00                   0.00
[Enter Other Specialist]                                                  0.00                                      0.00                   0.00
[Enter Other Specialist]                                                  0.00                                      0.00                   0.00
[Enter Other Specialist]                                                  0.00                                      0.00                   0.00
[Enter Other Specialist]                                                  0.00                                      0.00                   0.00
[Enter Other Specialist]                                                  0.00                                      0.00                   0.00
[Enter Other Specialist]                                                  0.00                                      0.00                   0.00
[Enter Other Specialist]                                                  0.00                                      0.00                   0.00
[Enter Other Specialist]                                                  0.00                                      0.00                   0.00
[Enter Other Specialist]                                                  0.00                                      0.00                   0.00
Total Specialist Compensation                             $               -    $               -   $                -    $                 -
Total Human Resources                                     $               -    $               -   $                -    $                 -
                     Other Overhead
Equipment Lease and Service Contracts:
                                    Photocopier Lease                     0.00                                      0.00                   0.00
                             Equipment Leases (specify)                   0.00                                      0.00                   0.00
                             Equipment Leases (specify)                   0.00                                      0.00                   0.00
                             Equipment Leases (specify)                   0.00                                      0.00                   0.00
                                                                                                                                                               08/05/08 V2.3
                                                                              EXPENDITURES
                                                                                                     Actual              Variance
                                                                                 Actual                                                     Variance Explanation/
                                                           Approved                                  Annual           (Overspending)/
                  Budget Categories                                                Q4                         2                                  Comments
                                                            Budget
                                                                   1                              Expenditures        Underspending
                                                                                                                                    3
                                                                               Expenditure
                       Column 1
                                                           Column 2             Column 3                              (Col. 2 - Col. 4)
                                                                                                    Column 4                                     Column 6
                                                                                                                        Column 5
                             Equipment Leases (specify)                0.00                                    0.00                  0.00
                             Equipment Leases (specify)                0.00                                    0.00                  0.00
                             Equipment Leases (specify)                0.00                                    0.00                  0.00
                             Equipment Leases (specify)                0.00                                    0.00                  0.00
                             Equipment Leases (specify)                0.00                                    0.00                  0.00
                             Equipment Leases (specify)                0.00                                    0.00                  0.00
                             Equipment Leases (specify)                0.00                                    0.00                  0.00
                    Equipment Service Contract (specify)               0.00                                    0.00                  0.00
                    Equipment Service Contract (specify)               0.00                                    0.00                  0.00
                    Equipment Service Contract (specify)               0.00                                    0.00                  0.00
                    Equipment Service Contract (specify)               0.00                                    0.00                  0.00
                    Equipment Service Contract (specify)               0.00                                    0.00                  0.00
                    Equipment Service Contract (specify)               0.00                                    0.00                  0.00
                    Equipment Service Contract (specify)               0.00                                    0.00                  0.00
                    Equipment Service Contract (specify)               0.00                                    0.00                  0.00
                    Equipment Service Contract (specify)               0.00                                    0.00                  0.00
                    Equipment Service Contract (specify)               0.00                                    0.00                  0.00
Sub-Total Equipment Lease and Service Contracts                        0.00                0.00                0.00                  0.00
                  4
General Overhead
                                             Advertising               0.00                                    0.00                 0.00
                                       Medical Supplies                0.00                                    0.00                 0.00
                              Communication Materials                  0.00                                    0.00                 0.00
  Cell Phone/Wireless Handheld/Telephone Line/Service                  0.00                                    0.00                 0.00
                      FHT Association Membership Fees                  0.00                                    0.00                 0.00
            Stationary/Printing/Copying/Postage/Courier                0.00                                    0.00                 0.00
                                         Office Supplies               0.00                                    0.00                 0.00
                                         Medical Waste                 0.00                                    0.00                 0.00
                                       Library Materials               0.00                                    0.00                 0.00
                                Payroll Service Contract               0.00                                    0.00                 0.00
                                             Translation               0.00                                    0.00                 0.00
                                 Other (please describe)               0.00                                    0.00                 0.00
                                 Other (please describe)               0.00                                    0.00                 0.00
                                 Other (please describe)               0.00                                    0.00                 0.00
                                 Other (please describe)               0.00                                    0.00                 0.00
                                 Other (please describe)               0.00                                    0.00                 0.00
                                 Other (please describe)               0.00                                    0.00                 0.00
                                 Other (please describe)               0.00                                    0.00                 0.00
                                 Other (please describe)               0.00                                    0.00                 0.00
                                 Other (please describe)               0.00                                    0.00                 0.00
                                 Other (please describe)               0.00                                    0.00                 0.00
                                                                                                                                                        08/05/08 V2.3
                                                                             EXPENDITURES
                                                                                                    Actual              Variance
                                                                                Actual                                                     Variance Explanation/
                                                          Approved                                  Annual           (Overspending)/
                  Budget Categories                                               Q4                         2                                  Comments
                                                           Budget
                                                                  1                              Expenditures        Underspending
                                                                                                                                   3
                                                                              Expenditure
                      Column 1
                                                          Column 2             Column 3                              (Col. 2 - Col. 4)
                                                                                                   Column 4                                     Column 6
                                                                                                                       Column 5
Sub-Total General Overhead                                            0.00                0.00                0.00                  0.00
Information Technology Other Operational Overhead
                          IT Hardware (Annual Ongoing)                0.00                                    0.00                 0.00
                           IT Software (Annual Ongoing)               0.00                                    0.00                 0.00
       Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                    0.00                 0.00
       Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                    0.00                 0.00
       Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                    0.00                 0.00
       Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                    0.00                 0.00
       Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                    0.00                 0.00
       Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                    0.00                 0.00
       Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                    0.00                 0.00
       Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                    0.00                 0.00
       Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                    0.00                 0.00
       Other IT Costs - Please Specify (Annual/Ongoing)               0.00                                    0.00                 0.00
Sub-Total IT Ongoing Overhead                                         0.00                0.00                0.00                 0.00
Travel                                                                0.00                                    0.00                 0.00
Professional Development                                              0.00                                    0.00                 0.00
Audit                                                                 0.00                                    0.00                 0.00
Legal                                                                 0.00                                    0.00                 0.00
General Consulting                                                    0.00                                    0.00                 0.00
Recruitment                                                           0.00                                    0.00                 0.00
Physician Consulting                                                  0.00                                    0.00                 0.00
Rent                                                                  0.00                                    0.00                 0.00
Property tax and Utilities                                            0.00                                    0.00                 0.00
Common Area Maintenance                                               0.00                                    0.00                 0.00
Security System                                                       0.00                                    0.00                 0.00
Insurance                                                             0.00                                    0.00                 0.00
Program Development Consulting                                        0.00                                    0.00                 0.00
Other Overhead (please describe)                                      0.00                                    0.00                 0.00
Other Overhead (please describe)                                      0.00                                    0.00                 0.00
Other Overhead (please describe)                                      0.00                                    0.00                 0.00
Other Overhead (please describe)                                      0.00                                    0.00                 0.00
Other Overhead (please describe)                                      0.00                                    0.00                 0.00
Other Overhead (please describe)                                      0.00                                    0.00                 0.00
Other Overhead (please describe)                                      0.00                                    0.00                 0.00
Other Overhead (please describe)                                      0.00                                    0.00                 0.00
Other Overhead (please describe)                                      0.00                                    0.00                 0.00
Other Overhead (please describe)                                      0.00                                    0.00                 0.00
Total Other Overhead Costs                                            0.00                0.00                0.00                 0.00
                                                                                                                                                       08/05/08 V2.3
                                                                                           EXPENDITURES
                                                                                                                           Actual               Variance
                                                                                                  Actual                                                                  Variance Explanation/
                                                                          Approved                                         Annual            (Overspending)/
                      Budget Categories                                                             Q4                              2                                          Comments
                                                                           Budget
                                                                                  1                                     Expenditures         Underspending
                                                                                                                                                           3
                                                                                                Expenditure
                           Column 1
                                                                          Column 2               Column 3                                     (Col. 2 - Col. 4)
                                                                                                                          Column 4                                             Column 6
                                                                                                                                                Column 5
                   One-Time Costs
Office Furnishings                                                                     0.00                                          0.00                   0.00
Clinical Equipment                                                                     0.00                                          0.00                   0.00
One-Time IT Hardware                                                                   0.00                                          0.00                   0.00
One-Time IT Software                                                                   0.00                                          0.00                   0.00
Signage                                                                                0.00                                          0.00                   0.00
One-Time Telecommunications                                                            0.00                                          0.00                   0.00
Moving Costs                                                                           0.00                                          0.00                   0.00
Other One-Time (please describe)                                                       0.00                                          0.00                   0.00
Other One-Time (please describe)                                                       0.00                                          0.00                   0.00
Other One-Time (please describe)                                                       0.00                                          0.00                   0.00
Other One-Time (please describe)                                                       0.00                                          0.00                   0.00
Other One-Time (please describe)                                                       0.00                                          0.00                   0.00
Other One-Time (please describe)                                                       0.00                                          0.00                   0.00
Other One-Time (please describe)                                                       0.00                                          0.00                   0.00
Other One-Time (please describe)                                                       0.00                                          0.00                   0.00
Other One-Time (please describe)                                                       0.00                                          0.00                   0.00
Other One-Time (please describe)                                                       0.00                                          0.00                   0.00
Total Start Up/One-Time Costs                                        $                 -    $               -       $                -    $                 -

Totals                                                   $               -    $                                 -   $                -   $                       -
Interest Rate in Interest-bearing account (e.g.; 3.00%)
Interest accrued from [Date of funds deposited] to [insert end of funding period]                                                        $                   -
Amount recoverable by the Ministry                                                                                                       $                   -
TOTAL MINISTRY FHT REVENUE                              $                                                           n/a                  n/a
OTHER REVENUE (PLEASE SPECIFY)                          $                                                           n/a                  n/a

1 As defined in Schedule B of the Interim Funding Agreement
2 Estimate of total expenditures incurred from end of this reporting period to the end of the current fiscal year (e.g. March 31, 2008)
3 Approved Budget Allocation minus Actual Annual Expenditures.
4 General Overhead expenditures must be reported on in
detail as per the sub-categories (e.g. medical supplies,
payroll service contract).

I certify that this is an accurate account of expenditures for the period specified.


SIGNED BY:________________________                                  SIGNATURE:_________________________________                                                      DATE:____________________




                                                                                                                                                                                      08/05/08 V2.3
                                                                                                                                                                                     Schedule "D"
                                                                                                                                                                Appendix 4 - Programs and Services Quarterly Report
                                                                                                                                                              [insert name of] Family Health Team, FHT Group #: XXX
                                                                                                                                                                                    For the Period
                                                                                                                                                                                    April 1, 2XXX
                                                                                                                                                                                           to
                                                                                                                                                                                   March 31, 2XXX
                                                                                                                 [Insert name of interdisciplinary health professional group (e.g. Nurse Practitioner, etc.)]; NB: Submit a separate template for each provider group

                                                                                                                                                        Q1 (Apr 1 - Jun 30)                                Q2 (Jul 1- Sep 30)                                Q3 (Oct 1 - Dec 30)                               Q4 (Jan 1 - Mar 30)                       TOTAL
                                                                                                                                             Total FTE:                                        Total FTE:                                         Total FTE:                                        Total FTE:




Acute & Episodic Care
                        Services                                                                                                                           # Patient Visits                                  # Patient Visits                                  # Patient Visits                                   # Patient Visits                    # Patient Visits




                        ■ Core primary care services provided in response to an acute or episodic illness or during a general health
                        assessment (e.g. treatment, consultation, general medication assessment, etc.)                                                                    Visits                                             Visits                                            Visits                                            Visits                            Visits



                        Chronic Disease Management Programs
                        A planned approach to care with documented, clear objectives and defined roles for providers, that focuses on
                                                                                                                                                           # Patient Visits                                  # Patient Visits                                   # Patient Visits                                  # Patient Visits                    # Patient Visits
                        maintaining the health of individuals with chronic conditions, delaying progression of their conditions, and
                        preventing complications.
                        Asthma                                                                                                                                            Visits                                             Visits                                            Visits                                            Visits                            Visits
                        COPD                                                                                                                                              Visits                                             Visits                                            Visits                                            Visits                            Visits
                        Cardiovascular Disease                                                                                                                            Visits                                             Visits                                            Visits                                            Visits                            Visits
                        Congestive Heart Failure                                                                                                                          Visits                                             Visits                                            Visits                                            Visits                            Visits
                        Hypertension                                                                                                                                      Visits                                             Visits                                            Visits                                            Visits                            Visits
                        Diabetes                                                                                                                                          Visits                                             Visits                                            Visits                                            Visits                            Visits
                        Mental Health                                                                                                                                     Visits                                             Visits                                            Visits                                            Visits                            Visits
                        Other (please specify):                                                                                                                           Visits                                             Visits                                            Visits                                            Visits                            Visits
Planned Care




                                                                                                                                                                          Visits                                             Visits                                            Visits                                            Visits                            Visits
                                                                                                                                                                          Visits                                             Visits                                            Visits                                            Visits                            Visits
                                                                                                                                                                       Total Visits                                      Total Visits                                       Total Visits                                      Total Visits                      Total Visits
                        Health Promotion & Disease Prevention Programs
                        A planned approach to care with documented, clear objectives and defined roles for providers, that focuses on                      # Patient Visits                                  # Patient Visits                                   # Patient Visits                                  # Patient Visits                    # Patient Visits
                        preventing diseases from occurring (e.g. screening, education, and counselling).

                        Periodic Health Exams                                                                                                                             Visits                                             Visits                                            Visits                                            Visits                            Visits
                        Cancer Screening                                                                                                                                  Visits                                             Visits                                            Visits                                            Visits                            Visits
                        Immunization (childhood/adult)                                                                                                                    Visits                                             Visits                                            Visits                                            Visits                            Visits
                        Addiction Counselling                                                                                                                             Visits                                             Visits                                            Visits                                            Visits                            Visits
                        Lifestyle and Wellness Counselling                                                                                                                Visits                                             Visits                                            Visits                                            Visits                            Visits
                        Other (please specify):                                                                                                                           Visits                                             Visits                                            Visits                                            Visits                            Visits
                                                                                                                                                                          Visits                                             Visits                                            Visits                                            Visits                            Visits
                                                                                                                                                                          Visits                                             Visits                                            Visits                                            Visits                            Visits
                                                                                                                                                                       Total Visits                                      Total Visits                                       Total Visits                                      Total Visits                      Total Visits

                        System Navigation

                                                                                                                                            ■ Do any of these providers participate in system ■ Do any of these providers participate in system ■ Do any of these providers participate in system ■ Do any of these providers participate in system
                        ■ Service coordination & referral to link patients with the appropriate provider / organization in the community,
                                                                                                                                            navigation? (Yes/No)                              navigation? (Yes/No)                              navigation? (Yes/No)                              navigation? (Yes/No)
                        including rehabilitation, outpatient & homecare services
                                                                                                                                                                           # FTEs                                            # FTEs                                             # FTEs                                            # FTEs
Indirect Patient Care




                                                                                                                                            ■ If YES, how many FTEs spend >50% of their       ■ If YES, how many FTEs spend >50% of their       ■ If YES, how many FTEs spend >50% of their       ■ If YES, how many FTEs spend >50% of their
                        ■ Assistance with hospital discharge planning
                                                                                                                                            workload on system navigation?                    workload on system navigation?                    workload on system navigation?                    workload on system navigation?

                        ■ Assistance with issues related to determinants of health (i.e. housing, social assistance, etc.)
                                                                                                                                                     # FTEs                                             # FTEs                                            # FTEs                                            # FTEs


                        Interdisciplinary Learning and Collaboration

                                                                                                                                            On average, how frequently do these providers     On average, how frequently do these providers     On average, how frequently do these providers     On average, how frequently do these providers
                        ■ Activities that support:                                                                                          participate in interdisciplinary learning and     participate in interdisciplinary learning and     participate in interdisciplinary learning and     participate in interdisciplinary learning and
                                                                                                                                            collaborative activities ?                        collaborative activities ?                        collaborative activities ?                        collaborative activities ?
                           ■ Interdisciplinary learning
                                                                                                                                            (Weekly/Bi-weekly/Monthly/As Needed)              (Weekly/Bi-weekly/Monthly/As Needed)              (Weekly/Bi-weekly/Monthly/As Needed)              (Weekly/Bi-weekly/Monthly/As Needed)
                           ■ Interprofessional consultation
                           ■ Team building and collaborative practice




                                                                                                                                                                                                                                                                                                                                                                               08/05/08 V2.3
                                                                                         Schedule "D"
                                                                      Appendix 5 - Physician Consulting Quarterly Report
                                                                   [insert name of] Family Health Team, FHT Group #: XXX
                                                                                         For the Period
                                                                                         April 1, 2XXX
                                                                                               to
                                                                                       March 31, 2XXX
Name of Reporting Physician
Consultant(s):

                                                                               Q1 (Apr-Jun)          Q2 (Jul-Sep)         Q3 (Oct-Dec)         Q4 (Jan-Mar)
Eligible Activities                                                                                                                                                      TOTAL
                                                                             # Hours / Quarter1   # Hours / Quarter1   # Hours / Quarter1    # Hours / Quarter1

Clinical Guidance to Interdisciplinary Providers                                                                                                                             0.0
Interdisciplinary Program Development                                                                                                                                        0.0
Meeting with Interdisciplinary Team Members                                                                                                                                  0.0
Meetings with MDs on Interdisciplinary Programs                                                                                                                              0.0
Program Monitoring and Reporting                                                                                                                                             0.0
Quality Assurance                                                                                                                                                            0.0
Other (specify)                                                                                                                                                              0.0
Other (specify)                                                                                                                                                              0.0

Total Hours                                                                         0.0                  0.0                   0.0                   0.0                     0.0
1
    Please indicate the total hours per quarter spent on each activity

Definitions:
Eligible Activities
Clinical Guidance to Interdisciplinary Providers - To develop recommendations for interdisciplinary providers on the appropriate treatment and care of people with specific diseases
and conditions (e.g. provide evidence-based and peer-reviewed guides to chronic disease care).
Interdisciplinary Program Development - To develop program directives; create implementation tools (e.g. provider checklists, self-care materials for patients); and, identify space,
resource and IT requirements for new programs.
Meeting with Interdisciplinary Team Members and MDs - To facilitate learning and training activities with FHT staff (e.g. team building, program development meetings,
interdisciplinary education, role identification, etc.).
Program Monitoring and Reporting - To ensure providers are adhering to program guidelines and directives; and, to provide ongoing support and feedback to FHT providers (e.g.
trouble-shooting, providing clinical support for providers, data collection and analysis, reporting research results etc.)
Quality Assurance - To evaluate and improve existing programs to address gaps in care and identify new health care needs (e.g. identifying new program objectives, updating and
revising program directives and tools, etc.).




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                                                                                                                Schedule "D"
                                                                                                 Appendix 6 - Hiring Status Quarterly Report
                                                                                          [insert name of] Family Health Team, FHT Group #: XXX
                                                                                                               For the Period
                                                                                                                April 1, 2XXX
                                                                                                                      to
                                                                                                              March 31, 2XXX
                                                                   Q1 (Apr-Jun)                                       Q2 (Jul-Sep)                                   Q3 (Oct-Dec)                                  Q4 (Jan-Mar)
                                                                                     Estimated /                                         Estimated /                                   Estimated /                                     Estimated /
                                                                 FTEs                  Actual                     FTEs                     Actual                  FTEs                  Actual                  FTEs                    Actual
           Management and Administrative Personnel
                                                     Approved    Hired     Vacant     Hire Date    Approved       Hired      Vacant       Hire Date    Approved    Hired     Vacant     Hire Date    Approved    Hired     Vacant       Hire Date
Executive Director                                       0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
Administrative Lead                                      0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
Administrative Lead (small FHT)                          0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
Finance Manager                                          0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
Office Administrator / Manager                           0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
Program Administrator                                    0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
Administrative Assistant                                 0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
Receptionist / Clerical Staff                            0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
Admin/Support for Blended Salary Model Physician         0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000
[Enter Other M or A Staff]                               0.000               0.000                     0.000                   0.000                       0.000               0.000                     0.000               0.000

TOTAL Management and Administrative Personnel            0.000     0.000     0.000                      0.000       0.000       0.000                      0.000     0.000     0.000                     0.000     0.000     0.000




                                                                                                                                                                                                                                  08/05/08 V2.3
                                                                                            Q1 (Apr-Jun)                                           Q2 (Jul-Sep)                                             Q3 (Oct-Dec)                                     Q4 (Jan-Mar)
                                                                                                                   Estimated /                                          Estimated /                                              Estimated /                                     Estimated /
                                                                                        FTEs                         Actual                    FTEs                       Actual                        FTEs                       Actual                  FTEs                    Actual
            Management and Administrative Personnel
                                                                          Approved        Hired      Vacant         Hire Date    Approved      Hired        Vacant       Hire Date      Approved         Hired       Vacant       Hire Date    Approved    Hired     Vacant       Hire Date
                                                                                        FTEs                       Estimated                   FTEs                      Estimated                      FTEs                     Estimated                 FTEs                  Estimated
Interdisciplinary Providers:                                              Approved        Hired      Vacant        Hire Date     Approved      Hired        Vacant       Hire Date      Approved         Hired       Vacant      Hire Date     Approved    Hired     Vacant      Hire Date
Nurse Practitioner                                                            0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Registered Nurse                                                              0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Registered Practical Nurse                                                    0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Registered Dietician                                                          0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Pharmacist                                                                    0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Social Worker                                                                 0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Social Worker (3 yrs. Exp + MSW)                                              0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Psychological Associate                                                       0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Psychologist                                                                  0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Health Educator/Promoter                                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Mental Health Worker                                                          0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Chiropodist/Podiatrist                                                        0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Case Worker/Manager                                                           0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
Speech Therapist                                                              0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
[Enter Other Interdisciplinary Provider]                                      0.000                    0.000                         0.000                    0.000                         0.000                      0.000                       0.000               0.000
TOTAL Interdisciplinary Providers                                               0.000       0.000       0.000                        0.000        0.000        0.000                          0.000        0.000         0.000                     0.000     0.000     0.000


                              Comments


DEFINITIONS:
Reporting Date - this is date of the IHP Hiring Status Report, e.g., the # of IHPs hired as of "March 31, 2008".

FTEs:
Approved - this column includes the type(s) of Health Professional Disciplines approved based on the business and operational plan submitted. This does not include conditionally approved FTEs.
Hired - this column includes the actual number of hired FTEs per AHP discipline based on your records as of the "Reporting Date", e.g., March 31, 2008.
Vacant - this column includes the actual number of vacant FTEs per AHP discipline based on your records as of the "Reporting Date", e.g., March 31, 2008 (it's calculated: "approved" less "Hired".
Estimated/Actual Hire Date - this column reports on estimated dates all vacant FTEs per IHP discipline will be hired by the Family Health Team. If the FTE has already been hired, please insert the actual hire date.
Comments - please provide brief description of your Team's recruitment plan.                                                                                                                                                                                                08/05/08 V2.3

				
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