Form chgme 100-1 chgme 100-1 chgme 100-1

---

Overview

HRSA 100-1-A CHILDREN'S HOSP ID
HRSA 100-1-B CH GME PROG STATUS
HRSA 100-1-C NO. OF TRAINEES SI
HRSA 100-1-D NO OF TRAINEES ROT
HRSA 100-1 - E LIST OF PROGRAMS
.

---

Sheet 1: HRSA 100-1-A CHILDREN'S HOSP ID

Department of Health and Human Services	OMB No.
Health Resources and Services Administration	Expiration Date: xx/xx/200x
See detailed guidance for complete instructions.
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-A: Children's Hospital Identification Information
Name of Children's Hospital
Address
City
State
Zip Code
Medicare Provider Number
Relevant fiscal year for application
Relevant academic year for application
Year your hospital first received CHGME funding
Submission Date of Annual Report	(mm/dd/yy)
Indicate years in which hospital received any CHGME funding :
	0
	0
	0
	0
	0
	0
	0
	0
Type of Application

---

Sheet 2: HRSA 100-1-B CH GME PROG STATUS

Department of Health and Human Services			OMB No.
Health Resources and Services Administration			Expiration Date: xx/xx/200x
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-B: Determination of Children’s Hospital GME Training Status
Hospital Name:	0
Medicare Provider Number:	0
Date of Report:	(mm/dd/yy)
How many outside institutions send residents to your hospital?
The table below ascertains accreditation "status" of your GME Programs. For each of the following programs, check the box if
your children's hospital is a sponsoring institution, major participating institution, and/or rotation site for an accredited
program (check all that apply). If your children's hospital is not involved in a given program, check "not applicable." There
must be at least on box check for each program listed. (but not for "Other: specify") Indicate with an "*" those GME
training programs that have not yet undergone approval by the ACGME or another accrediting body. If you need to add
additional programs that are not listed, please use "Other: Specify" options at the end of the table. See detailed guidance for
complete instructions.
	Sponsoring Program	Major Participating Institution or Rotation Site/Other Participating Institution	Not Aplicable
Primary Care Programs
Family Medicine	0	0	0
Pediatrics	0	0	0
Combined Programs
Internal Medicine Pediatrics	0	0	0
Pediatrics/Dermatology	0	0	0
Pediatrics/Emergency Medicine	0	0	0
Pediatrics/Medical Genetics	0	0	0
Pediatrics/Physical Medicine and Rehab	0	0	0
Pediatrics/Psychiatry/Child & Adolescent Psych	0	0	0
Pediatric Medical Subspecialties
Adolescent Medicine Pediatrics	0	0	0
Child Abuse Pediatrics	0	0	0
Developmental Behavioral Pediatrics	0	0	0
Hospice and Palliative Medicine	0	0	0
Medical Toxicology	0	0	0
Neonatal-Perinatal Medicine	0	0	0
Neurodevelopmental Disabilities	0	0	0
Pediatric Cardiology	0	0	0
Pediatric Critical Care Medicine	0	0	0
Pediatric Emergency Medicine	0	0	0
Pediatric Endocrinology	0	0	0
Pediatric Gastroenterology	0	0	0
Pediatric Hematology/Oncology	0	0	0
Pediatric Infectious Disease	0	0	0
Pediatric Nephrology	0	0	0
Pediatric Pulmonology	0	0	0
Pediatric Rheumatology	0	0	0
Pediatric Transplant Hepatology	0	0	0
Pediatric Sports Medicine	0	0	0
Pediatric Surgical Subspecialties
Pediatric Cardiothoracic Surgery	0	0	0
Pediatric Neurosurgery	0	0	0
Pediatric Ophthalmology	0	0	0
Pediatric Orthopedics	0	0	0
Pediatric Otolaryngology	0	0	0
Pediatric Surgery	0	0	0
Pediatric Urology	0	0	0
Other Specialties
Child and Adolescent Psychiatry	0	0	0
Child Neurology	0	0	0
Emergency Medicine (Pediatric)a	0	0	0
Pediatric Anesthesiology	0	0	0
Pediatric Dermatology	0	0	0
Pediatric Pathology	0	0	0
Pediatric Radiology	0	0	0
Pediatric Rehabilitation Medicine	0	0	0
General (Non-pediatric) Specialties
Anesthesiology	0	0	0
Colon & Rectal Surgery	0	0	0
Dermatology	0	0	0
Emergency Medicine	0	0	0
Medical Genetics	0	0	0
Neurological Surgery	0	0	0
Neurology	0	0	0
Nuclear Medicine	0	0	0
Obstetrics and Gynecology	0	0	0
Ophthalmology	0	0	0
Orthopedic Surgery	0	0	0
Otolaryngology	0	0	0
Pathology	0	0	0
Physical Medicine & Rehabilitation	0	0	0
Plastic Surgery	0	0	0
Preventive Medicine	0	0	0
Psychiatry	0	0	0
Radiology	0	0	0
Surgery	0	0	0
Thoracic Surgery	0	0	0
Urology	0	0	0
Allergy Immunology	0	0	0
Pediatric Sleep Medicine	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0	0
Other (specify):__________________	0	0
a. Refers to program in which residents first completed an emergency medicine residency followed by a pediatric emergency medicine fellowship versus initially completing a pediatric residency followed by a pediatric emergency medicine fellowship.

---

Sheet 3: HRSA 100-1-C NO. OF TRAINEES SI

Department of Health and Human Services				OMB No.
Health Resources and Services Administration				Expiration Date: xx/xx/200x
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-C: Number of FTE Trainees - Sponsoring Institution
Hospital Name:	0
Medicare Provider Number:	0
Date of Report:	(mm/dd/yy)
For each accredited GME program for which your children’s hospital is a sponsoring institution, please indicate the number of approved FTE resident positions, the number of FTE resident positions recruited to fill, number of FTE resident positions filled, and number residents in FTE training positions in your hospital. Only the programs that are checked on "HRSA 100-1-B Children's Hospital Program Status" appear and should be completed. Please report the total number across all PGY years.
For accredited programs, the number of ACGME approved positions should be entered in Column B. The number of recruited positions (Column C) refers to the number of positions the program actively attempted to fill for the last academic year, Column D is the number of Positions filled, and Column E is the number of FTE residents training in the program. See detailed guidance for complete instructions.
	Number of Approved Resident Positions	Number of Recruited Positions	Number of Positions Filled	Number of Residents in FTE Training Positions
Primary Care Programs
N/A
N/A
Combined Programs
N/A
N/A
N/A
N/A
N/A
N/A
Pediatric Medical Subspecialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Pediatric Surgical Subspecialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Other Specialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
General (Non-pediatric) Specialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
a. Refers to program in which residents first completed an emergency medicine residency followed by a pediatric emergency medicine fellowship versus initially completing a pediatric residency followed by a pediatric emergency medicine fellowship.

---

Sheet 4: HRSA 100-1-D NO OF TRAINEES ROT

Department of Health and Human Services				OMB No.
Health Resources and Services Administration				Expiration Date: xx/xx/200x
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-D Major Participating Institutions and Rotation Sites - Number of FTE Trainees Meeting 75% Standard
Hospital Name:	0
Medicare Provider Number:	0
Date of Report:	(mm/dd/yy)
For each GME program for which your children’s hospital is a major participating institution or a rotation site, please indicate the number of approved positions, the number of FTE resident positions recruited to fill, the total number of residents rotating in the program, and the number of FTEs for which the trainee spends at least
75% of their training time under supervision of your hospital. Only the programs that are checked on "HRSA
100-1-B Children's Hospital Program Status" appear and should be completed. Please report the total number
across all PGY years. These numbers should be summed and reported across all program years (e.g., PGY1
through PGY4 for general pediatrics, etc.
Please note: If you do not have any approved positions or you have not recruited for any positions, please place a "N/A" in the relevant field. See detailed guidance for complete instructions.
	Number of Approved Positions	Number of Recruited Positions	Number of Residents Rotating through Programs in the Most Recent Academic Year	Number of Trainees Spending ³ 75% under Children’s Hospital Supervision
Primary Care Programs
N/A
N/A
Combined Programs
N/A
N/A
N/A
N/A
N/A
N/A
Pediatric Medical Subspecialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Pediatric Surgical Subspecialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Other Specialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
General (Non-pediatric) Specialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
a. Refers to program in which residents first completed an emergency medicine residency followed by a pediatric emergency medicine fellowship versus initially completing a pediatric residency followed by a pediatric emergency medicine fellowship.

---

Sheet 5: HRSA 100-1 - E LIST OF PROGRAMS

Department of Health and Human Services				OMB No.
Health Resources and Services Administration				Expiration Date: xx/xx/200x
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-E: Programs for which an Annual Report is Required
Hospital Name:	0
Medicare Provider Number:	0
Date of Report:	(mm/dd/yy)
For each program listed below, please fill out the separate annual report worksheet. Please be sure to scroll to the bottom of worksheet to see all highlighted programs. See detailed guidance for complete instructions. Thank you.
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0
N/A	0

---

Sheet 6: .

Initial completion of annual report

Data missing from initial application