Information Collection

Children's Hospital Graduate Medical Eduction Payment Program

IC 6495 under ICR 200701-0915-003 · OMB 0915-0247.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0247 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HRSA 99-2 Children's Hospital Graduate Medical Eduction Payment Program	Form and Instruction
HRSA 99-2 HRSA 99-2 Excel Version of HRSA 99-2.xls	Form and Instruction
HRSA 99-3 HRSA 99-3 HRSA 99-3 .doc	Form and Instruction
HRSA 99-1 HRSA 99-1 Excel Version of HRSA 99-1.xls	Form and Instruction
HRSA 99-4 HRSA 99-4 Excel Version of HRSA 99-4 .xls	Form and Instruction
HRSA 99-5 HRSA 99-5 HRSA 99-5 .doc	Form and Instruction
Application Guidance - revised June 2006 as a result of Section 422 of the MMA.doc Application Guidance - revised June 2006 as a result of Section 422 of the MMA	IC Document
HRSA 99 - updated June 2006.doc HRSA 99 - updated June 2006	IC Document

IC Title:

Children's Hospital Graduate Medical Eduction Payment Program

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HRSA 99-2	HRSA 99-2	Excel Version of HRSA 99-2.xls	Yes	Yes	Fillable Fileable
Form and Instruction	HRSA 99-3	HRSA 99-3	HRSA 99-3 .doc	Yes	Yes	Fillable Fileable
Form and Instruction	HRSA 99-1	HRSA 99-1	Excel Version of HRSA 99-1.xls	Yes	Yes	Fillable Fileable
Form and Instruction	HRSA 99-4	HRSA 99-4	Excel Version of HRSA 99-4 .xls	Yes	Yes	Fillable Fileable
Form and Instruction	HRSA 99-5	HRSA 99-5	HRSA 99-5 .doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	60	0	60
Annual IC Time Burden (Hours)	4,140	300	3,840
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Application Guidance - revised June 2006 as a result of Section 422 of the MMA	Application Guidance - revised June 2006 as a result of Section 422 of the MMA.doc	01/17/2007
HRSA 99 - updated June 2006	HRSA 99 - updated June 2006.doc	01/17/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.